PET INTAKE FORM FOR ANNUAL EXAMS – Veterinarians Stratford

Please answer the questions below and submit to us before your scheduled appointment. Thank you!

Date

Name

First Last

Phone

Email

Emergency Contact Number

What other pets are in the household?*

What diet do you feed your pet?*

How do you feed your pet?*

Scheduled
Free fed (food is left out all the time and filled when empty)
Not sure

If scheduled, how much and how often?*

Cups	Cans	Times per day

Does your pet get treats? (eg. table scraps, bones, Greenies, Temptations)?*

Yes
No

Is your pet on any medications or supplements (eg. Glucosamine, omegas)?*

Yes
No

If so, please list (with doses if possible - click the "+" to add more)*

Medication	Dose

Does your pet do any travelling (eg. cottage, camping, to the USA)?*

Yes
No

Excluding the above pets in household, does your pet interact with other animals? (eg. dog park/boarding/grooming/day care/obedience/wildlife/stray cats)?*

Yes
No

Is your pet exposed to young children/elderly/immunocompromised individuals? (eg. Cancer patients, pregnant women)*

Yes
No

Of these common parasites, which are you concerned about? (Check all that apply)*

Fleas
Ticks
Worms
Heartworms
None

Please indicate if you have noticed any changes with the following: (Check all that apply)*

If you checked any of the above, please explain:

What is(are) the MAIN concern(s) you would like to have addressed at this appointment?*

Is your pet a cat? If so, we would like you to answer some additional questions.*

Yes
No

How often does your cat spend time outdoors (including porch/balcony/yard)?*

Frequently
Occasionally
Never

How often does your cat urinate or defecate outside of the litterbox?*

Frequently
Occasionally
Never

How often does your cat vomit, cough or have hairballs?*

Frequently
Occasionally
Never

How often does your cat scratch things other than their scratching post (eg. furniture, carpet)?*

Frequently
Occasionally
Never

How often does your cat hunt birds, rodents or insects?*

Frequently
Occasionally
Never

How often does your cat hiss or fight with other pets?*

Frequently
Occasionally
Never
Not Applicable

Thank you again for filling out this form. The information will help us provide the best individualized care for your pet.

The Coventry Animal Hospital Health Care Team

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PET INTAKE FORM FOR EXAMS

Please answer the questions below and submit to us before your scheduled appointment. Thank you!