Examination Questionnaire

Thank you for bringing your pet in for an examination. We hope we will be able to set your mind at ease after your appointment. Thank you for taking out the time to fill out our questionnaire and sending it in as soon as possible 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 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).

What is the best phone number for the veterinarian to call once the examination is complete to discuss exam findings and diagnostic/treatment recommendations? *

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?

I have concerns today about my pet's:

• Ears
• Eyes
• Skin
• Mobility
• Vomiting/Diarrhea
• Breathing
• Heart
• Behaviour
• Pain levels
• Eating/Drinking
• Teeth
• Weight
• Overall Health
• Other

If other, please list.

Describe your concerns about your pet. What symptoms are you noticing?

When did you first notice your pet's symptoms?

Has your pet's eating or drinking habits changed since you began noticing symptoms?Please SelectYesNo

Eg. Eating or drinking more, eating or drinking less, poor appetite, dropping food out of his/her mouth, painful to chew, more frequent refilling of the water bowl, drinking from the toilet when they didn't used to etc

If yes, please tell us more.

Has your pet's energy levels or behaviour changed since noticing symptoms?Please SelectYesNo

Eg. Lethargic, loss of interest in activities, sleeping more or less, hyperactivity, growling, biting, anxiety etc.

If yes, please tell us more.

Has there been any change in urinating or defecating habits?Please SelectYesNoI don't know

Eg. Increased or decreased frequency, going outside the litter box, having accidents in the house, straining to urinate or defecate, blood in the stool or urine, crying out, hard or soft stools, diarrhea, constipation etc

If yes, please tell us more.

Has your pet gained/lost significant weight since you have noticed symptoms?Please SelectYesNo

Eg. lost/gained weight in a short time period, weight gain/loss noticed by measuring on a scale, looks like they have gained/lost weight, feels heavier/lighter when picking them up.

If yes, please describe.

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

Eg. Limping, favouring a side, reluctance to go up or down stairs, crying out, not jumping on furniture that they used to, decreased activity etc.

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

Does your pet have health insurance?Please SelectYesNo

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

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