330-925-4910
allcreaturesfax@gmail.com
Facebook
Facebook
Home
About
About Us
Our Team
Photo Gallery
Reviews
All Creatures Fund
Services
Clinic Services
Lodge Services
Resources
Newsletters
Forms
Pre-Exam Questionnaire
New Client Form
Boarding and Daycare Form
Online Pharmacy
Careers
Contact
Book Appointment
Select Page
We’re now accepting new patients!
Pre-Exam Questionnaire
Fill out the form below and a member of our team will get back to you shortly if we have any questions.
get started
7
Pre-Exam Questionnaire Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Patient Name:
Please list all medications your pet is currently taking:
Below you will find a checklist of common indicators of medical problems in pets. Please mark each that applies in order to facilitate the diagnostic process for our doctors and staff. This greatly assists us in providing the best possible care:
Increased or decrease in appetite
Increase or decrease in drinking
Increase or decrease in weight
Change in frequency of urination/amount of urine
Any diarrhea or vomiting
Problems with control of urination or bowel movements
Behavioral changes/abnormal behavior (i.e. increased aggression, disinterested, etc.)
Apparent confusion, disorientation, pacing, vertigo
Irregular sleep patterns/restlessness
Limping, stiffness, discomfort
Lethargy and/or difficulties with physical activity
Itchy, irritated, and/or flaky skin
Any new or growing bumps or lumps
Head shaking/dirty ears/head shaking
Abnormal coughing and/or sneezing
Difficulty eating and/or mouth odor
My pet is healthy, and does not appear to have any of the problems listed above.
Please list any other concerns you would like to discuss below:
Have you recently traveled anywhere within the continental United States? If so, please list:
Have you recently traveled anywhere outside the continental United States? If so, please list:
Extracurricular activities (check all that apply):
Boarding
Daycare
Dog Park
Grooming
Pet Store
Other
If 'Other', please specify:
Submit