Appointment Questionnaire | Animal Doctor Blue Hills

First name *

Last name *

Preferred contact number. *

Patient name *

NEW PATIENTS ONLY: How long have you had the patient?

NEW PATIENTS ONLY: Where did you get him/her?

NEW PATIENTS ONLY: Is the patient microchipped?

NEW PATIENTS ONLY: Vaccination history (be specific)

NEW PATIENTS ONLY: Does the patient have any underlying conditions?

NEW PATIENTS ONLY: If yes, please explain.

How long have you noticed a problem with the ears? *

Which ears are affected? *

Left

Right

Both

How is the pet behaving? Scratching, shaking, or in pain? *

Has your pet had previous problems with the ears? Please explain. *

CATS ONLY: How often does your cat go outside? Does he/she go outside on a leash or on a screened in porch?

Has your pet been recently bathed or gone swimming? *

Have you tried anything at home? When is the last time you cleaned the ears? *

Any history of allergies? *

What kind of food are you feeding? How much per day? Table scraps/ treats? *

Is the patient on any medications? Include dosage and frequency. *

Are you administering heartworm preventative? What type and how often? *

Are you administering flea/ tick preventative? What type and how often? *

Do you have any additional questions or concerns you would like to address with the Doctor today? *

Animal Doctor Blue Hills