Examination Questionnaire

Thank you for bringing your pet in for an examination. We hope we will be able to set your mind at ease after your appointment. Thank you for taking out the time to fill out our questionnaire and sending it in as soon as possible prior to your appointment. This allows us to get to review how your pet has been doing before the appointment so we can focus in on the things that really matter to you. Please feel free to call 705-522-4555 or email info@lockerbyanimalhospital.com if you have any questions.

CLIENT & PET INFORMATION

Owner/Co-Owner First and Last Name(s) *

Email Address *

Pet's Name *

Pet's Date of Birth

Appointment Date and Time

Who will be bringing your pet to the appointment?

(If this person is not the owner, please indicate their relationship to you and if they are able to make medical and financial decisions on your behalf).

What is the best phone number for the veterinarian to call once the examination is complete to discuss exam findings and diagnostic/treatment recommendations? *

Please list any medications or supplements your pet is currently taking:

Has your pet had any adverse reactions to any medications in the past? If so, which medication and what was their reaction?

If other, please list:

Describe your concerns about your pet. What symptoms are you noticing?

When did you first notice your pet's symptoms?

Has your pet's eating or drinking habits changed since you began noticing symptoms? If yes, please tell us more.

Eg. Eating or drinking more, eating or drinking less, poor appetite, dropping food out of his/her mouth, painful to chew, more frequent refilling of the water bowl, drinking from the toilet when they didn't used to etc.

Has your pet's energy levels or behaviour changed since noticing symptoms? If yes, please tell us more.

Eg. Lethargic, loss of interest in activities, sleeping more or less, hyperactivity, growling, biting, anxiety etc.

Has there been any change in urinating or defecating habits? If yes, please tell us more.

Eg. Increased or decreased frequency, going outside the litter box, having accidents in the house, straining to urinate or defecate, blood in the stool or urine, crying out, hard or soft stools, diarrhea, constipation etc.

Has your pet gained/lost significant weight since you have noticed symptoms? If yes, please describe.

Eg. lost/gained weight in a short time period, weight gain/loss noticed by measuring on a scale, looks like they have gained/lost weight, feels heavier/lighter when picking them up.

Have you noticed any changes in your pet's mobility? If yes, please tell us how long it has been happening, what makes it worse, what relieves it.

Eg. Limping, favouring a side, reluctance to go up or down stairs, crying out, not jumping on furniture that they used to, decreased activity etc.

Have you signed your pet up for health insurance?

Do you have any specific concerns with your pet that you would like addressed at your appointment?

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Examination Questionnaire

CLIENT & PET INFORMATION

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