Pre-Appointment Health Questionnaire

Animal General Hospital — Pre-Appointment Health Questionnaire

Please complete one questionnaire per pet before the scheduled appointment. Select the answers that best describe your pet. This form does not schedule an appointment. For urgent concerns, call 772-344-8835.

Your first name

Your last name

Best telephone number

Email address

Pet name

Pet species

Dog

Cat

Scheduled appointment date (if known)

Drinking water

Normal

More than usual

Less than usual

Not sure

Any vomiting recently?

Yes

Not sure

Any diarrhea or abnormal stool recently?

Yes

Not sure

Any change in urination, straining, or accidents?

Yes

Not sure

Any coughing or sneezing recently?

Yes

Not sure

Any itching, ear trouble, or skin changes?

Yes

Not sure

Any limping, stiffness, or signs of pain?

Yes

Not sure

Does your pet take any medications or supplements?

Yes

Not sure

Does your pet have a diagnosed ongoing medical condition?

Yes

Not sure

Any known medication allergies or previous vaccine reactions?

Yes

Not sure

Does your pet need special handling because of fear, biting, or scratching?

Yes

Not sure

Medication names, known conditions, reactions, or anything else we should know (optional)

Animal General Hospital — Pre-Appointment Health Questionnaire

Best telephone number

Scheduled appointment date (if known)

Drinking water

Normal

More than usual

Less than usual

Not sure

Any vomiting recently?

Yes

Not sure

Any diarrhea or abnormal stool recently?

Yes

Not sure

Any change in urination, straining, or accidents?

Yes

Not sure

Any coughing or sneezing recently?

Yes

Not sure

Any itching, ear trouble, or skin changes?

Yes

Not sure

Any limping, stiffness, or signs of pain?

Yes

Not sure

Does your pet take any medications or supplements?

Yes

Not sure

Does your pet have a diagnosed ongoing medical condition?

Yes

Not sure

Any known medication allergies or previous vaccine reactions?

Yes

Not sure

Does your pet need special handling because of fear, biting, or scratching?

Yes

Not sure

Medication names, known conditions, reactions, or anything else we should know (optional)