Pre-Visit Questionnaire

Please have this form completed before coming to the hospital.

• Please call our office once you have arrived: 913-825-3330
• WHY DO I NEED AN ESCORT INTO THE BUILDING? The reason we have someone escort you and your pet from your car to the exam room has to do with the fact that we are extremely short-handed at our front desk. By following our current approach, anyone in the hospital can answer the phone, notify an assistant, and the technician can check you and your pet into the room.
• Today's Date*
  MM slash DD slash YYYY
• Name*
• Pet's Name*
• Cell phone where you can be reached*
• Alternative phone number (optional)
• Briefly describe the reason your pet is here for an exam, such as ear infection, sick, limping, etc.*

• Please answer all questions below regardless of why your pet is here.

• Tell us all the foods and treats your pet eats.
• What medications and supplements does your pet take?
• Has your pet had any coughing?*
  • Yes
  • No
• Has your pet had any sneezing*
  • Yes
  • No
• Does your pet have any nasal discharge?*
  • Yes
  • No
• If yes, what color and which nostril(s)?
• Has your pet been vomiting?*
  • Yes
  • No
• If your pet has been vomiting when was the last time and describe the vomit
• Has your pet had diarrhea?*
  • Yes
  • No
• When was the last time you saw your pet's bowel movement and what did it look like?
• Has your pet been drinking more?*
  • Yes
  • No
• Has your pet been urinating more?*
  • Yes
  • No
• If your pet's urine appears abnormal, please describe:
• Has your pet’s appetite changed?*
  • Yes
  • No
• if so describe how
• Any change in diet?*
  • Yes
  • No
• If yes, when and what did you change?
• Is your pet lethargic (not active)?*
  • Yes
  • No
• If yes, how long?
• Is your pet here because it is limping?*
  • Yes
  • No
• If so which leg and how long?
• Please list all medications your pet is on and when they were last given:
• Does your pet have a problem with one or both of its eyes?*
  • Yes
  • No
• Which eye, describe any drainage or symptoms.
• Does your pet have a problem with one or both of its ears?*
  • Yes
  • No
• Which ear, describe any discharge or symptoms.
• Do you have a concern with your pet’s teeth?*
  • Yes
  • No
• If yes, describe.
• Please use this space to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.
• CAPTCHA
• Name
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