Swan Creek Veterinary Clinic
PRE EXAM QUESTIONNAIRE
Owners Name: *
Pets Name *
Today's date: *
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Is any human in your household sick, feverish, or diagnosed with Covid-19 in the past 14 days? *
Primary reason for your pets visit today (If limping, please notate which leg. If a lump or wound has been noticed, please describe the location): *
How long has your pet been experiencing this problem? *
Please describe the symptoms you are noticing: *
Has your pet been eating, drinking,urinating, and having bowel movements normally? If no, please describe: *
Has your pet had any coughing, sneezing, vomiting or diarrhea? If yes, please describe: *
What type of pet food and/or treats, and what amount are you currently feeding? *
Is your pet on any medications or supplements currently? If yes, please describe: *
Do you need any medication or food refills today? *
Does your pet need any Heartworm or Flea and Tick preventatives today? *
Any other information or concerns we should know about today's visit? *
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