Office: 970-879-5273
mail@petkareclinic.com

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Pet Wellness Exam Questionnaire

Pet Wellness Exam Questionnaire

Pet Wellness Exam Questionnaire

"*" indicates required fields

Client Info

Your Name*

First Last

Email*

Update your personal information

I would like to update other information (address, alternate contact, alternate phone, payment information, etc.)

Updated Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Updated Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Updated Email Address

Updated Primary Phone

Updated Cell Phone

Updated Work Phone

Updated Spouse Cell Phone

Updated Person Responsible for Authorizing Procedures and Making Payments

Include any additional information to update here

Pet Information

Pet Name*

Type of Pet*

Cat

Dog

Other

Age of Pet*

Approximate age okay. For pets older than 7, we will collect a bit of additional info.

1-7 years old

Older than 7 years

This field is hidden when viewing the form

Date of Exam

Recent History

Since your last visit, has your pet experienced any of the following symptoms (check all that apply):

Vomiting

Vomiting

If vomiting, how many times per day, and for how many days?

Diarrhea

Diarrhea

If diarrhea, how many times per day, and for how many days?

Coughing, Sneezing and Water Consumption

Coughing

Sneezing

Change in water consumption

For change in water consumption

More water consumption

Less water consumption

Does your pet exhibit any of the following:

Limping

Limping (if so, which limb, duration?)

Limping Details

Itching/chewing/licking

Itching/chewing/licking (if so, location, frequency, progression?)

Itching/chewing/licking Details

Lumps/bumps

Lumps/bumps (If so, location, size, and is it bothering your pet?)

Lumps/bumps Details

If yes, please explain

Is your pet eating and drinking regularly?

Yes

No

If no, please describe

What do you feed your pet (include brand, protein source, dry/canned)

How much do you feed your pet (quantity, frequency, free fed)?

Do you feed your pet treats/table scraps? If so, what and how much?

Do you do anything for your pet’s dental care at home?

Yes

No

If yes, please describe

Does your pet have a history of any allergies or vaccination reactions?

How would you describe your pet’s energy level?

List any medications or supplements that your pet is on. Includes doses, frequency, and how administered:

Do you travel or plan to travel with your pet?

Yes

No

If yes, where and when did you (or will you) travel?

Have you noticed any new or changed behaviors in your pet?

If un-spayed, when was the last heat cycle or presentation of breeding/mating behavior?

Do you have any other questions or concerns for the doctor?

For Cats

Does your pet spend time indoors, outdoors, or both?

Is your pet a hunter?

Have you noticed any changes in mobility or willingness to jump onto higher places?

What are your pet’s grooming habits?

Has your pet been using a litterbox regularly?

For Dogs

How much do you exercise your pet on a daily basis?

Have you noticed any changes in mobility?

Do you administer regular heartworm preventative medication?

Yes, year-round

Yes, seasonally

No

Do you give your pet a flea and tick preventative?

Yes, year-round

Yes, seasonally

No

For Pets Older than 7 Years

Have you noticed any of the following:

Any limping or hesitancy to jump up/down?

Any changes in energy level?

Any behavioral changes or changes in sleep patterns?

Any changes in appetite or eating behavior?

Other Information

Has your pet seen another vet (other than us) during the past year?

Yes

No

If yes, name and address of the facility or clinic:

May we contact the vet or facility that your pet visited?

Yes

No

Do you have pet insurance?

Do you have the Pet Kare Clinic smartphone App?

Yes

No

Not sure

Location

Contact Us

102 Anglers Drive (Location)
Steamboat Springs, CO 80487 Po Box 776134, 80477

Email: mail@petkareclinic.com

Office: 970-879-5273
Fax: 970-797-6390

Hours: Mon-Thur, 8-6
Fri, 8-5; Sat, 9-2

Our Mission

To treat you and your pet like one of our own, with unparalleled compassion, experience and teamwork.

Steamboat’s Only
AAHA-Accredited Clinic

Association of
Feline Practitioners

Colorado Veterinary
Medical Association

American Veterinary
Medical Association

US Department of
Agriculture Accredited

Steamboat’s Only
AAHA-Accredited Clinic

Association of
Feline Practitioners

Colorado Veterinary
Medical Association

US Department of
Agriculture Accredited

Steamboat’s Only
AAHA-Accredited Clinic

Association of
Feline Practitioners

Colorado Veterinary
Medical Association

American Veterinary
Medical Association

US Department of
Agriculture Accredited

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