Annual Feline Examination Appointment Questionnaire

Name: Lockerby Animal Hospital
Telephone: 705-522-4555

We are happy to see your pet for their annual examination! We feel that this is an integral part of maintaining your pet’s quality of life and allows us to detect any diseases/conditions before they progress into something more serious. Thank you for taking out the time to fill out our questionnaire prior to your appointment. This allows us to get to review how your pet has been doing before the appointment so we can focus in on the things that really matter to you. Please ensure you bring a sample of your pet’s stool to the appointment (about a teaspoon size, fresh within the last 24 hours) so we can test for intestinal parasites. Please feel free to call 705-522-4555 or email info@lockerbyanimalhospital.com if you have any questions.

Owner/Co-Owner First and Last Name(s) *

Pet's First and Last Name *

Pet's Date of Birth

Appointment Date and Time

Who will be bringing your pet to the appointment? (If this person is not the owner, please indicate their relationship to you and if they are able to make medical and financial decisions on your behalf).

Please list any medications or supplements your pet is currently taking.

Has your pet had any adverse reactions to any medications in the past? If so, which medication and what was their reaction?

Is your pet eating and drinking well?

If no, please tell us more.

What are you currently feeding your pet? Please list amount, frequency treats.

Have you noticed any recurrent vomiting, diarrhea, coughing or sneezing?

If yes, please tell us more.

Has there been any change in urinating or defecating habits?

If yes, please tell us more.

Have you noticed any bad breath, bleeding gums, difficulty chewing or dropping of food?

If yes, please describe.

Are you doing any oral home care?

Is your pet scratching or do they seem itchy?

If yes, please describe where they are scratching and how frequently.

Have you noticed any changes in your pet's mobility?

If yes, please tell us how long it has been happening, what makes it worse, what relieves it.

Have you noticed any growths or lumps on your pet?

If yes, where is it and how long have you noticed it there for?

Have you noticed any behavioural changes in your pet?

If yes, please provide details and tell us how long have you been noticing the behaviour?

Are there any other pets in your home?

If yes, what species and is everyone getting along well?

Please help us understand your pet's lifestyle by clicking all activities that are applicable to you and your pet.

My pet goes in the backyard.
My pet goes to camp or does outdoor camping.
My pet goes hiking in the woods.
My pet stays strictly indoors (not even the backyard).
My pet travels out of town with me.
My pet travels to the southern states in the winter.
My pet visits the groomer.
My pet goes to a boarding facility.

Does your pet have health insurance?

Do you have any specific concerns with your pet that you would like addressed at your appointment?

Annual Feline Examination Appointment Questionnaire

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