Pet Health Questionnaire

Which practice would you like to register with?

Location

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CLIENT INFORMATION

Full Name *

Phone Number *

Email *

Clinic your appointment is at

Pembroke Animal Hospital
Deep River Animal Services
Mohns Avenue Veterinary Services

PET INFORMATION

Pet's Name *

Brand name of food

Amount Fed

How often fed

How much exercise/activity does your pet receive?

Active
Moderate
Little

How do you feel about your pet’s weight?

Overweight
Normal
Underweight

Check all that apply

I like to give my pet some of my own food
I like to give my pet some of my own food
I give my pet flea/tick medication
I give my pet vitamins or supplements
I give my pet medications
I give my pet heartworm medication

Does your pet have outdoor access?

Never
Sometimes
All Day

Please give us more detail on any problems you selected or other concerns you have. Note when problem started and how often it occurs or has it changed?

Does your pet have any important medical history or illnesses we should know about?
Make note of any lethargy, if your pet is hiding, any skin issues, and behavioural concerns.

Do you have any other questions you like us to answer or address?

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY * *