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(210) 494-3436 Make an Appointment

Home » PET MEDICAL HISTORY QUESTIONNAIRE

PET MEDICAL HISTORY QUESTIONNAIRE

Date

MM slash DD slash YYYY

OWNER

PATIENT NAME

PLEASE ANSWER EACH QUESTION BELOW

Is your pet coughing?

YES

NO

IF YES, HOW LONG?

Is your pet sneezing?

YES

NO

IF YES, HOW LONG?

Is your pet vomiting?

YES

NO

IF YES, HOW LONG?

Does your pet have diarrhea?

YES

NO

IF YES, HOW LONG?

Is your pet eating/drinking well?

YES

NO

IF YES, HOW LONG?

Is your pet urinating/defecating normally?

YES

NO

IF YES, HOW LONG?

Is your pet itchy/scratching/licking/ chewing excessively?

YES

NO

IF YES, HOW LONG?

Any new lumps/bumps or changes to existing lumps/bumps?

YES

NO

IF YES, HOW LONG?

Is your pet limping/having trouble getting around?

YES

NO

IF YES, HOW LONG?

Is your pet currently on heartworm, flea, or tick prevention?

YES

NO

If yes, when was the last dose given and what brand/type

Is your pet currently on any medications?

YES

NO

If yes, please list the medication(s)

What food does your pet currently eat?

DRY

WET

Please name the brand/type:

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17203 Jones Maltsberger, Ste. 106,
San Antonio, TX 78247

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Monday

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Tuesday

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Wednesday

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Thursday

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Friday

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Saturday

Closed

Sunday

Closed

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