CLIENT INFORMATION

Canine Pre-Admission Questionnaire

: Thank you for booking your appointment with us. The following information is to provide background information for your pet’s visit. Please complete this form and press 'Submit' when completed.
Client Name:: Please enter your first name and surname
Appointment Location:: Please select the location of your appointment
: About your dog
Patient Name:: Please enter your pet's name
Age:: Please enter in years/months
Length of Ownership:: Please enter in years/months
Where did you obtain your pet?:: Please select origin
Other Option
Has your dog been desexed?:: Please select preference
Other Option
Age when desexed (if applicable):: Please enter in years/months
: Your dog's diet
What is your dog's diet?:: Please select preference
Other Option
Please specify food brand:
Please list any treats or supplements given:
Your Dog's Environment and Energy Levels: Your dog's environment and energy levels
Indoor/Outdoor Status:
If outdoors is it a:
Other Option
Please list any other pets in the household (eg. 1 dog, 2 cats):
Do any of the other pets have similar signs/problem?:
How active is your dog?:
Have there been recent changes in activity levels?:
: Travel History
Has your dog travelled:
Please specify region(s) visited:
: Preventative Medications
Are your dog's vaccinations:
Date of last vaccination:: dd/mm/yyyy
Heartworm prevention:
Product used:
Date given:: dd/mm/yyyy
Tick prevention:
Product used:
Date given::: dd/mm/yyyy
Worming:
Product used:
Date given:: dd/mm/yyyy
: Previous Illness
Has your dog had any previous accidents or illnesses? (unrelated to the current problem):
If yes please list:
: Toxin Exposure or Adverse Reactions to Medications
Has your dog been exposed to any known toxins?:
If yes please list:
Has your dog had a reaction to a medication or vaccination in the past?:
If yes please list:
: Current Medications
: Your clinician will review these medications with you at your consultation.
Is your dog receiving any medications?:
If yes please list:
I find it easiest to medicate my dog:
: Vet Details
Who is your regular vet?:
Have you seen any other vets for the current problem?:
If yes please list:
: Thank you for this information. We will add this to your pet's file for their visit with VSS. We look forward to helping you soon. Regards the team at VSS

VSS
Veterinary
Hospital

Underwood Vet Hospital

Underwood

1-15 Lexington Rd, Underwood QLD 4119

P : (07) 3841 7011 F : (07) 3841 7022

Email Us >Visit Google Map >

Carrara Vet Hospital

Carrara

104 Eastlake St, Carrara QLD 4211

P : (07) 5530 6370 F : (07) 5559 1308

Email Carrara Visit Google Map >

Jindalee Vet Hospital

Jindalee

24/34 Goggs Rd, Jindalee QLD 4074

P : (07) 3193 6500 F : (07) 3188 9004

Email Jindalee Visit Google Map >

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