We ask that you fill out our Appointment Questionnaire prior to your appointment with Stoney Creek Veterinary Hospital.

Appointment Questionnaire

Date Form Completed *

The Cell Phone Number of the person coming to the appointment with your pet *

Name of Patient *

Reason For Today's Visit *

What diet is your pet currently on? Brand names, frequency, people food, etc. *

Pet Lifestyle - Select the following that applies to your pet *

Go outside

Go to the park or go hiking

Go to daycare/ boarding / grooming facility

During the last month, have any of the following problems occurred?

General

Weight Loss

Weight Gain

Vomiting

Diarrhea

Change in appetite

Coughing and/or sneezing

Increased thirst or urination

Have you noticed any of the following in your pet?

Skin

Lumps, bumps, sores or swelling on their skin? *

Yes

If yes, are there any changes in growth, and hardness or discomfort for your pet?

Yes

What is the duration of time since you've noticed this?

Excessive scratching, licking of paws or irritation? *

Yes

If yes, what is the duration of time since you've noticed this?

Ears

Ear problems? (Scratching, shaking head, discharge, foul smell) *

Yes

If yes, is it their right ear, left ear, or both?

Right

Left

What is the duration of time since you've noticed this?

Eyes

Vision Changes? *

Yes

Irritation, redness or discharge? *

Yes

If yes to either, what is the duration of time since you've noticed this?

Dental

Bad breath, trouble chewing, tartar? *

Yes

If yes, what is the duration of time since you've noticed this?

Mobility

Lameness, stiffness, difficulty on stairs or walking? *

Yes

Any other evidence of arthritis? *

Yes

If yes to either, what is the duration of time since you've noticed this?

Please use to following section to provide us information about medications your pet is currently taking. Include:

The Name of the Medication

The Medication's Strength (Example: 50mg, 100mg, etc)

How You Give It To Your Pet (How much/many? How often?)

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Will you require any medication refills while you are here? *

Yes

If yes, what is the name of the medication?

Does your pet take any preventatives (flea and tick heartworm, etc)? *

Yes

If yes, what is the name of the preventative?

If your pet take preventatives, do they do so every month?

Yes

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Happy Tails from Clients

I have been going here for many years with my cats and I trust this hospital and the doctor so much I'm willing to drive twice as long as I normally would use this vet.... Very good service very knowledgeable and helpful.
- Clare I.

Appointment Questionnaire