Patient Questionaire

Please fill out this questionnaire as best you can. Feel free to leave things blank or report anything you feel is relevant.
Please submit it this as soon as possible prior to your appointment so that we may focus our visit on your pet’s care.

Please email your pet’s medical records at least 1 business day prior to your appointment to: info@vox.vet.

* Indicates required field

Your Name *

First

Last

Email *

Pet’s name *

Phone Number *

What is your main concern regarding your pet’s health and what would you like to accomplish during our appointment? *

On a scale from 0-10 (0 being no pain and 10 being the worse, extreme pain) how much pain do you feel your pet is experiencing at it’s worse? *

What symptoms are your noticing (or, what behaviours have changed?) *

What medication and/or supplements is your pet currently taking? *

What other medications have you tried and why are they no longer taking them? *

What is your pet’s diet and how is his/her appetite? *

What other therapies/care is your pet receiving (rehab/PT/ homeopathy/ acupuncture etc) ? *

What is your pet' environment (indoor, footing,and do you have other pets? *

Described your pet's environment/living arrangement *

Other pets in the house? Does your pet engage with them? Any children in the household? Does your pet engage with him/her/them? *

When feeling good, what is your pet's personality like? Any behavior issues? Please also add any other comment you'd like me to know. *

Please choose the reason(s) for your appointment. *

Pain Consult Acupuncture Quality of Life Consult Medical History Review

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