Pre-Visit Medical Questionnaire Skip to Main Content Skip to Footer

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Download Our App
(770) 963-6903

Services
Hours & Location
About Us
Contact

Pre-Visit Medical Questionnaire

Please provide the following information to help us evaluate your pet more thoroughly.

Pet Name:*

Is your pet exhibiting any of the following symptoms? (select all that apply)*

Vomiting

Diarrhea

Appetite Change

Limping

Coughing

Sneezing

Bad Breath

Pain While Chewing

Reluctant to Play

Excessive Thirst or Urination

Acting Confused

Itching

Lethargic

Weight Gain

Weight Loss

Seizures/Convulsions

Acting Painful

None of these

Other

What food does your pet eat?*

How often does your pet eat?*

Is your pet on heartworm prevention?*

Yes

No

If yes, what kind of heartworm prevention?

Is your pet on flea &/or tick control?*

Yes

No

If yes, what kind of flea &/or tick control?

Please list all of your pet's medications or supplements below (type, how often):

Does your pet spend any time outdoors?*

Yes

No

Please list any of your pet's previous surgeries and the reason for the surgery:

Please let us know if your pet has ever been hospitalized and why:

Are there other issues occurring with your pet that you would like for us to be aware of?

Our practice has the philosophy that we would rather prevent a health problem than have to treat one. We also believe that it is very important to catch any disease process early in its course while it is still manageable and hopefully curable. Laboratory work is an invaluable tool in veterinary medicine.

Even if your pet is acting normal, other things can be going on “behind the scenes.” Lab work also serves as a baseline for future comparison should your pet become sick at a later time. It also stands for most presurgical lab work procedures should your pet require surgery within the next few months.

Our practice has a special “package” price for laboratory profiles. Would you be interested in having such laboratory work performed today?*

Yes

No

Gwinnett Animal Clinic

190 Buford Drive
Lawrenceville, GA 30046

phone: (770) 963-6903
email us

Proudly serving the Lawrenceville, GA area, including (but not limited to): Dacula, Buford, Suwanee, Grayson, Snellville, Auburn, and Winder.

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