Veterinary Services Questionnaire

Thank you for Choosing Alta Vista Veterinary Hospital!So we may provide your dog with the best care possible, please carefully fill out this questionnaire to the best of your ability.

Please note that exams preformed for daycare/boarding vaccines are only to ensure that your pet is healthy enough to be vaccinated. If you have any specific concerns please contact Alta Vista Animal Hospital to book an appointment.
Client Name*
Phone*
Arrival Date*

MonthDayYear
Date
Checkout Date*

MonthDayYear
Date
Pet Name*
Breed*
Age*
Spayed/Neutered?*
Reason for visit :*
Who is/was your primary veterinary hospital?:*
What is their telephone number and address
Last Rabies vaccination

MonthDayYear
Date
Last Distemper/Parvo vaccination

MonthDayYear
Date
Last Bordetella vaccination

MonthDayYear
Date
Last Feline Leukemia vaccination

MonthDayYear
Date
Last FVRCP vaccination

MonthDayYear
Date
Last FELV/FIV test

MonthDayYear
Date
Describe your pets environment*

Strictly indoorsstrictly outdoorsBoth indoors and outdoors
Is your pet microchiped*
Has your pet been tested for parasites in the last year?*
Heartworm prevention?*
Has your pet experienced any injury or illness in the past 30 days?*

YesNoOther
Is your pet currently taking any medications?*

YesNoOther
Is your pet allergic to any drugs/medications/food?*

YesNoOther
How many times a day do you feed your pet?*
When is the last time your pet was fed?*
Do you give your pet treats?*

YesNo
Appetite?*
Body Weight?*
Water Consumption?*
Urination?*
Bowel Movements?*
If change in bowel movement, how long has this been occurring?
Please check all that apply*

IncontinenceLoss of house-trainingStraining to UrinateVomitingCoughingPantingSneezingGaggingListlessnessWeaknessShaking HeadScratchingSignificant Hair LossScootingUnusual LumpsBad BreathDischargeLamenessLimpingDifficulty RisingStiffnessBehavioral ChangesNo changesOther
If patient should need the following I give permission to Alta Vista Veterinary Hospital to do the following? (check all you authorize Alta Vista to perform)*

Exam: $85
Please add any additional comments/concerns you may wish to have addressed on your visit to Alta Vista Veterinary Hospital.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty: