Foothill Farms Veterinary Hospital Pre-Visit Questionnaire
Please fill out the following form prior to your appointment. Thank you very much
Name *
Phone Number *
Pet's Name *
Date of scheduled appointment *
If you do not have a scheduled appointment, please call us at (916) 332-4444 to schedule prior to completing this form.
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Please describe the reason for your visit *
Does your pet have any other current or pertinent previous health history? *
What diet is your pet on? *
Is your pet on flea, tick, intestinal parasite and heartworm prevention? *
If yes, please list brand, date of last dose and if you need any refills?
Please list any current medications that your pet is on. If you can, please include the drug name, the strength, the frequency and when it was last administered. If your pet is not on any medications, please write "none". *
Has your pet had any changes in energy, appetite or thirst? *
Increased
Decreased
Same
Energy
Appetite
Thirst
Is your pet having any changes in their urination habits? Select all that apply *
Required
Does your pet have any of the following *
Yes
No
Diarrhea
Vomiting
Coughing
Sneezing
If you answered yes, please elaborate
Please rate your pet's anxiety during Veterinary visits *
Happy and calm
Extremely nervous, stressed or aggressive
Does your pet have any favorite treats or any food allergies that we should be aware of? We love to use treats during the visit.
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