Client Name*

Patient Name*

Email*

Is your pet nervous when they come to the hospital? Our staff have been trained in Fear Free techniques and we have ways to help.

Yes
No

Does your pet require calming medication for their visit?*

Yes
No
Unsure

If you require medication, please contact the clinic at least 24 hours prior to your appointment for a refill.

(For cats) Is your cat indoors only or indoor/outdoor?*

Indoor
Outdoor
Indoor/Outdoor

If outdoor, do they have contact with wildlife or other outdoor pets?*

Yes
No

(For dogs) Does your dog go to the dog park, groomer or a boarding facility or have social time with dogs from other households?*

Dog Park
Groomer
Boarding Facility
Social Time
None of the Above

Please select all that apply.

(For dogs) Does your dog tend to drink from an outdoor water source (ponds/puddles) or have access to wildlife areas or nature trails?*

Yes
No

Has your pet experienced any significant health changes since their last visit?*

Yes
No

If yes, please describe.

Is your pet currently on any medications or supplements?*

Yes
No

If yes, please list the name(s), dose(s), and frequency of administration of the medication(s)/supplement(s)

If you need a refill of any of these medications or supplements, please detail the requested quantity so we may prepare it ahead of their appointment.

What diet does your pet eat, how much and how often? Please include any treats, supplements and human food.*

Have you noticed any changes in your pet's mobility or activity level? Are they able to move around comfortably?*

Yes
No

If yes, please describe.

Have you observed any changes in your pet's behaviour, temperment, or cognitive function? (e.g., increased aggression, confusion, anxiety, dazed appearance, etc.)*

Yes
No

If yes, please describe.

Is your pet experiencing any issues with sleeping patterns or restlessness at night?*

Yes
No

If yes, do they get up during the night to:

Urinate
Defecate
Drink Water
Pant
Pace
Whine/Cry
Bark/Meow

Please select all that apply.

Have you noticed any changes in your pet's sight or hearing?*

Yes
No

If yes, please describe.

Have there been any recent changes in appetite or thirst?*

Yes
No

If yes, please describe.

Have you noticed any changes in your pet's urinary habits, such as increased frequency or accidents in the house or outside the litterbox?*

Yes
No

If yes, please describe.

Have you noticed any changes in your pet's bowel movements? Any vomiting?*

Yes
No

If yes, please describe.

Has your pet experienced any dental issues, such as bad breath, difficulty chewing, or swollen gums?*

Yes
No

If yes, please describe.

Any coughing or sneezing?*

Yes
No

If yes, please describe.

Any new lumps or bumps? Any changes to lumps or bumps that have been previously noted?*

Yes
No

If yes, please describe.

Please provide any additional information or details you believe may be helpful for our veterinary team to know.

Are there any additional procedures you would like to request with your appointment?

Social Media Consent: Do you give Ilderton Pet Hospital permission to take photos of your pet, identify them by name, and share them on our official Facebook and Instagram pages?

YES
NO

***Parasites can pose a human health risk. We recommend bringing a fresh (within 24 hours) fecal sample to check for internal parasites every year or more frequently if there are any digestive concerns or high risk for parasite exposure. ***

We thank you for taking the time to fill out this form and we look forward to seeing you and your companion soon.

Email

This field is for validation purposes and should be left unchanged.

Senior Annual Wellness Pre-Visit Questionnaire

Senior Pet Annual Wellness Pre-Visit Questionnaire

Mailing Address

Office Hours

Monday	8:30am – 5:00pm
Tuesday	8:30am – 5:00pm
Wednesday	8:30am – 5:00pm
Thursday	8:30am – 5:00pm
Friday	8:30am – 5:00pm
Saturday	8:30am – 12:00pm
Sunday	Closed