Identification of Clients/Patients

Your name

Date of your appointment

Time of your appointment

You are
—Please choose an option—A new clientAn existing client

You animal’s name

It is
—Please choose an option—An intact male catAn intact female catA castrated male catA spayed female catAn intact male dogAn intact female dogcastrated male dogA spayed female dog

My animal is
—Please choose an option—A new patient of the ClinicAn existing patient of the Clinic

Veterinary consult purpose

Consult purpose:
—Please choose an option—Routine examinationThere is a problem with my companion

Your animal’s lifestyle

Your animal lives
—Please choose an option—Inside onlyOutside onlyInside and outside

Has your animal ever travelled outside of the province?
—Please choose an option—YesNo

Is your companion living with other animals?
—Please choose an option—YesNo

Does your animal have contact with other animals outside the home?
—Please choose an option—YesNo

Does your animal go to daycare?
—Please choose an option—YesNo

Does your animal go to the groomer?
—Please choose an option—YesNo

When did your companion see a veterinarian last?
—Please choose an option—In the last yearMore than 1 and less than 3 yearsMore than 3 yearsMy animal has never seen a veterinarian

Was your companion vaccinated in the last 3 years?
—Please choose an option—YesNoI don’t know

Is your companion microchipped?
—Please choose an option—YesNoI don’t know

Has your animal ever been tested for the Feline Leukemia and Immunodeficiency viruses (FELV/FIV test for cats)) or for key vector borne diseases (SNAP 4DX test for dogs)?
—Please choose an option—YesNoI don’t know

Has your animal been tested in the last year for gastro-intestinal parasites?
—Please choose an option—YesNoI don’t know

Has your animal been preventively tested against parasites in the last year?
—Please choose an option—YesNoI don’t know

Useful information to assess your animal’s health

How would you qualify your companion’s appetite level?
—Please choose an option—Eats a lotEats normallyEats only a littleDoesn’t eat

What is the name of the food your companion is eating?

What type of food is it?
—Please choose an option—KibblesCannedKibbles and CannedRawOther

Your animal vomits
—Please choose an option—NeverSometimesOften

Do stools look normal?
—Please choose an option—YesNo

Do you see diarrhea?
—Please choose an option—NeverSometimesOften

Does your animal’s urination appear normal?
—Please choose an option—YesNo

Your animal drinks
—Please choose an option—NormallyLess than beforeMore than before

Is your animal scratching itself excessively?
—Please choose an option—YesNo

Is your companion coughing?
—Please choose an option—YesNo

Is your animal sneezing?
—Please choose an option—YesNo

Is your animal walking normally?
—Please choose an option—YesNo

Has the behaviour of your companion changed?
—Please choose an option—YesNo

Is your animal taking medications?
—Please choose an option—YesNo