Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire for Louisville Family Animal Hospital

*Required Field

Appointment Date

Pet Owner Name

First Name

Last Name

Contact Number

Email Address

Pet Name

What is the primary reason for your visit?

What medications or supplements does your pet take? Please include doses and frequency.

What does your pet eat? Please include the brand, flavor(s)/variety(ies), the amount fed, and the frequency of meals.

If your pet has vomiting or diarrhea:

When did this start?

How many times does your pet vomit/have diarrhea each day?

Have there been any recent changes in diet, treats, meds, etc?

Do you think your pet may have eaten something inappropriate (toys, rocks, etc)?

If your pet has an injury:

Where on your pet’s body is the injury?

When do you think the injury occurred?

Do you know how your pet was injured?

Have you given any medications (prescription or OTC)?

What home care have you provided?

For other issues (ear infections, coughs, rashes, etc)

How long has this issue been going on?

What have you done for this issue (food change, medication, etc)?

What seemed to help? What did not help?

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