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Home
About Us
-Veterinarians
-Chillicothe Team
-Dunlap Team
-Peoria Team
-What to Expect
-Precious Pets Grooming Staff
-Loyalty Program
-H.A.L.O.
-Employment Opportunities
Services
-Medical Services
-Boarding
-Grooming
-Surgical Services
-Wellness Programs
-Avian & Exotics
-Laser Therapy
-Preventative Services
-Oncology
-Diagnostics
-Microchipping
Contact
Resources
-New Client Form
-News
-Online Store
-Links
-Pet Library
-Pet Portal
-New Patient Questionnaire
-Coupons
Cancer Clinic
New Patient Questionnaire
Home
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New Patient Questionnaire
Name
*
First
Last
Pet's Name
*
Pet's Age
Phone
*
Email
*
Reason for Appointment
What do you currently feed your pet?
Have you noticed any changes in your pets appetite or thirst?
*
Yes
No
If yes, what are the changes?
Have you noticed any abnormal vomiting or diarrhea?
*
Yes
No
Has your pet lost or gained a significant amount of weight since your last visit?
*
Yes
No
Has your pet had any problems urinating or defecating?
*
Yes
No
Does your pet go camping and/or hunting?
*
Yes
No
Does your pet go outside unsupervised or have exposure to wildlife?
*
Yes
No
Does your pet sleep in bed with you or your children at night?
*
Yes
No
Do you board your pet when you leave town?
*
Yes
No
Does your pet swim or get bathed frequently?
*
Yes
No
Does your pet get groomed or go to dog parks or other public places?
*
Yes
No
Has your pet ever had blood work done before?
*
Yes
No
If yes, when was the blood work last done?
*
And why?
*
Is your pet currently on monthly Heartworm prevention?
*
Yes
No
If yes, what kind?
Is your pet currently on any monthly flea or tick preventative?
*
Yes
No
If yes, what kind?
Does your pet have pre-existing medical conditions?
*
Yes
No
If yes, what conditions?
Is your pet currently on any other medications?
*
Yes
No
If yes, what kind?
Have you noticed any limping or other concerns with your pet's mobility?
*
Yes
No
If yes, explain
Is your pet microchipped?
*
Yes
No
Is your pet spayed/neutered?
*
Yes
No
Does your pet receive any home dental care?
*
Yes
No
If yes, what kind?
Do you have any children or grandchildren in the household?
*
Yes
No
Did you bring in fecal sample today to check for intestinal parasites?
*
Yes
No
Would you prefer a topical or oral pill for parasite prevention?
Topical
Oral
Do you have any specific concerns or questions for the doctor today?
