History for Annual Wellness Exam

Name of Pet(Required)

First Last

Date of Upcoming Wellness Exam Visit(Required)

Phone number of owner coming to visit(Required)

Current Medications and Supplements (including heartworm/flea/tick prevention)(Required)

*Include name of medication and current dosing instructions

Pet's Current Diet(Required)

*Include brand of food and how much feeding per day.

Describe your pet's lifestyle(Required)

*For example: daycare, boarding, grooming, dog parks, walks in woods, indoor/outdoor cat, etc

Owner Requests for Visit(Required)

*For example, nail trim, anal glands, medication refills needed today or upcoming.

Questions and Concerns for Doctor(Required)

*Any changes in eating, drinking, urination, defecation, litter box use, vomiting, diarrhea, coughing, sneezing, scratching, head shaking?

Please list size and location of any new or existing lumps or skin lesions. Note if any have grown or changed in appearance.

Any concerns for your pet's mobility or movement? (See checklists below)

Checklists to assess mobility for dogs: https://www.zoetispetcare.com/checklist/osteoarthritis-checklist. And cats: https://www.zoetispetcare.com/checklist/osteoarthritis-checklist-cat

History for Annual Wellness Exam

History for Annual Wellness Exam

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