Mandeville-Examination Questionnaire

Client Name

Pet’s Name

Dog

Cat

Male

Female

Color

Weight

Age

Hidden

Please check the significant problems that apply to your pet and prioritize by number

Please check the significant problems that apply to your pet and prioritize by number

Coughing

Itching Skin

Lethargic

Losing Weight

Vomiting

Limping

Times per day

Front,Rear,Left.Right?

Difficulty Defecating

Eye Discharge

Nose Discharge

Shaking Head

Scratching Ears

Seizures

Times per: Day,Week,Month

Sneezing

Other

How long has your pet displayed these problems?

Describe your pet’s appetite and drinking habits

Describe your pet’s urine and bowel habit

No Change

Increased Urine

Increased Stool

Formed Stool

Semi-formed Stool

Watery Stool

Hidden

What are you currently feeding your pet

What are you currently feeding your pet

Dry Food, which brand?

Canned food, which brand?

Other Food (raw,human/table food)

If yes, what were you previously feeding?

Is this a recent change?

Yes

If yes, what were you previously feeding?

List any lumps/bumps that you would like checked

Where does your pet spend his/her time?

Only Indoor (never outside)

Mainly Indoor

Mainly Outdoor

Equally In/outdoor

Is your pet currently receiving a monthly intestinal and heartworm preventative?

Yes

If yes, what kind and what day of the month?

Is your pet currently receiving a monthly flea/tick/external parasite preventative?

Yes

If yes, what kind and what day of the month?

Is your pet currently receiving any other medications? Please list medications and dosages

In order to diagnose your pet’s condition, your pet may require blood tests, x-rays, and/or other diagnostic testing. Do you authorize tests if the doctor feels they are warranted?

Yes

Do Not proceed with any doctor recommended diagnostic testing

Would you like to be called with an estimate prior to any treatment?

Yes

It is very important that the doctor is able to contact you if they have any questions regarding your pet. If the doctor is unable to reach you it may result in a postponement of treatment. List all numbers where you can be reached today

2nd

List any other comments/questions

Drop Off Exams are offered for your convenience. Your pet will be examined when the doctor’s schedule allows (critical patients will be examined immediately). Pick up times cannot be guaranteed,but we will try our best to accommodate your schedule.*