Patient ReCheck Questionnaire

Today's Date

Owners Name

First Last

Pet's Name

Please use as much detail as possible!

Has your pet improved since their last visit?

If not, please describe the ongoing problem

Have you noticed any new symptoms? Is your pet coughing, sneezing, or vomiting?

If yes, please describe

Is your pet having normal stools and urinating regularly?

If not, please describe

Is your pet’s food and water intake normal?

If not, please describe

What is your pet’s regular diet? (Please list brand, amount and how many times a day the pet is fed)

Is your pet on any medications (prescribed or not prescribed)/monthly prevention/nutraceutical supplements at this time?

If yes, please list the medications, the doses of the medications that you gave, and the time that they were given

Are you able to administer medications to your pet?

Do you prefer tablets or liquid medications, if possible

Do you have any specific questions or concerns for the doctor at this time?