Wasatch Hollow Animal Hospital - Wellness/Annual Pre-Exam Client Form

Please complete this form as thoroughly as possible before your appointment.
This helps our team review medication response, side effects, and refill needs efficiently

Client name

Pet name

Date

MM slash DD slash YYYY

Phone

Species

Breed

Age

Sex

Weight

Doctor/Team

Main concerns and recent health

Any major concerns you want addressed today?

Has your pet been sick recently?

Coughing

Sneezing

Vomiting

Diarrhea

Lethargy

Decreased appetite

No concerns

Details/notes:

Any vaccine reactions in the past?

Yes

Unsure

Details:

Any allergies to medications, vaccines, or foods?

Yes

Unsure

Details:

Current medications or supplements? Include dose/frequency if known. Medication refills needed today?

Any recent medical care elsewhere, ER visits, urgent care, vaccines, or procedures?

Prevention, lifestyle, and exposure

Heartworm and flea/tick prevention status

Current

Not current

Unsure

Lifestyle

Indoor only

Outdoor only

Both

Does your pet go to social settings?

Boarding

Grooming

Daycare

Dog parks

Training classes

Other

None

Details/notes:

Exposure risks

Wildlife

Livestock

Chickens

Goats

Rodents

Standing water

Hiking/camping

Details/notes:

Household, travel, and nutrition

Is your pet around other dogs/cats?

Dogs

Cats

Both

Details:

Has your pet traveled recently, or do you have planned travel?

What diet/brand is your pet eating?

How much and how often do they eat?

Any table food, treats, chews, bones, or raw diet?

Eating, drinking, urination, and stool

Water intake

Normal

Increased

Decreased

Unsure

Urination

Normal

Increased

Decreased

Accidents

Straining

Blood

Unsure

Details/notes:

Stool

Normal

Soft

Diarrhea

Constipation

Straining

Blood

Mucus

Unsure

Details/notes:

Other concerns

Any concerns with:

Weight

Dental health

Skin

Ears

Lumps

Mobility

Behavior/anxiety

None

Details/notes:

Is there anything else you want the doctor to know before your appointment?

Thank you. This helps our team review your pet's history and concerns before the doctor enters the room.