Pet History Questionnaire - Wilmot Veterinary Clinic

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Name

First

Last

Pet's Name

Does your pet experience any stress, anxiety or fear when visiting a veterinary clinic? If yes, please explain.

Weight gain or loss? Yes or no? If yes, please explain.

Appetite increase or decrease? Yes or no? If yes, please explain.

Vomiting or diarrhea? Yes or no? If yes, please explain.

Constipation or difficult defecation? Yes or no? If yes, please explain.

Increased drinking or urination? Yes or no? If yes, please explain.

Lumps, tumors, or skin problems? Yes or no? If yes, please explain.

Bad breath, sore gums, or difficulty chewing? Yes or no? If yes, please explain.

Decreased awareness or confusion? Yes or no? If yes, please explain.

House soiling or spraying? Yes or no? If yes, please explain.

Decreased recognition of people or animals? Yes or no? If yes, please explain.

Decreased affection or interaction with owner? Yes or no? If yes, please explain.

Chewing, licking, or eating non-food items? Yes or no? If yes, please explain.

Increased irritability or aggression? Yes or no? If yes, please explain.

Increased fear or anxiety? Yes or no? If yes, please explain.

Decreased tolerance of handling? Yes or no? If yes, please explain.

Loss of hearing or sight? Yes or no? If yes, please explain.

Repetitive behaviours like pacing or excessive grooming? Yes or no? If yes, please explain.

Decreased grooming or self-care? Yes or no? If yes, please explain.

Muscle tremors or shaking? Yes or no? If yes, please explain.

Weakness or incoordination? Yes or no? If yes, please explain.

Difficulty climbing stairs? Yes or no? If yes, please explain.

Decreased activity or an increase in sleep? Yes or no? If yes, please explain.

Excessive vocalization? Yes or no? If yes, please explain.

Eye problems? Yes or no? If yes, please explain.

Scratching or odour from ears? Yes or no? If yes, please explain.

Scratching or chewing skin or paws? Yes or no? If yes, please explain.

Have you ever seen your pet eat snails, slugs, rodents, rabbits and/or feces? Yes or no? If yes, please explain.

Have you ever found fleas or ticks on your pet? Yes or no? If yes, please explain.

Current Medication:

Existing Medical Problems:

Please describe your pet's current diet (brand, amount, frequency):

Do you travel outside of KW with your pet? If yes, where?

Any other concerns: