Pet Health Questionnaire Form

Welcome to Paws of Pleasanton!

Pet Health Questionnaire Form

Please fill out this form before your pet’s exam so we can provide the best care possible. Please update us if you have had an address or phone number change.

Owner Information

Owner’s Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet Information

Pet's Name *

First

Last

Species/Breed *

Age/Date of Birth *

Pet Sex *

Male
Neutered Male
Female
Spayed Female

Reason for Visit *

Wellness Exam
Vaccines
Illness Concern
Recheck / Follow-Up
Other

If Other:

Please describe your main concern or reason for today’s visit. If the reason for the visit is an illness, please describe the symptoms and duration of the illnesses/concerns and if any treatment has been implemented at home. *

Medical History

Current Diet (brand/type, treats): *

Current Medications (name, dose, frequency). Please provide any other medications you are giving your pet. This includes supplements. *

Flea/Tick/Heartworm Prevention? *

Product: *

Any recent changes in:

Appetite *

Normal
Increased
Decreased

Drinking *

Normal
Increased
Decreased

Urination *

Normal
Increased
Decreased

Bowel Movements *

Normal
Diarrhea
Constipation
Other

If other: *

Activity/Energy *

Normal
Increased
Decreased

Any coughing, sneezing, vomiting, limping, or other concerns? *

Known allergies (food, medication, environmental, vaccine reaction)? *

General Health

Does your pet have a history of medical conditions (skin, dental, seizures, arthritis, etc.)? *

Any scooting, head shaking, or licking of the paws? *

Any surgeries or hospitalizations in the past? If so, when and what clinic? *

Any lumps, bumps, or changes you’ve noticed? *

Are any other pets in the household experiencing similar symptoms? *

Lifestyle

Indoor / Outdoor / Both? *

Any travel in the last 6 months? *

If yes, where did you travel? *

Contact with other animals (dog parks, boarding, grooming, daycare)? *

Additional Notes or Concerns for the Doctor:

Owner’s Signature: *

Clear Signature

Date *

Phone

Contact

Phone: 925-380-1888
Email: [email protected]

Location

3128 Santa Rita Road, Suite B
Pleasanton, CA 94566

Hours

Mon - Fri: 7:30 am - 6:00 pm
Sat - Sun: Closed

Have a question?

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