Annual Appointment Questionnaire Pet NameClient NameDate Date Format: MM slash DD slash YYYY Reason for visit:1. Is your pet on flea, tick or heartworm medications? If yes, what brand?2. Is your pet on any prescriptions or supplements?3. What type of food is your pet eating?4. Are there any concerns with your pets behavior or obedience?5. Do you currently have a dental care routine for your pet?6. Has your pet had a history of vaccine reactions?7. Are there any concerns or problems you would like the doctor to address?YesNoClient questions:1. Have you or anyone in your household had COVID19? If so, when?YesNoIf so, when?2. Have you or anyone in your household had any respiratory illness or other symptoms like loss of taste or smell in the past 2 weeks?3. What is the best phone number to reach you at?Is there anything else you’d like us to be aware of regarding your pet or yourself?
