Health Questionnaire

1 Step 1

Owner Name

Pet Name

Date

Pet Medical History

Thyroid DiseaseYes/No. If Yes, please descibe.

Allergies/allergic to anythingYes/No. If Yes, please descibe.

Seizures (please describe frequency, severity, cause of occurrence, behavior to look for, etc.)Yes/No. If Yes, please descibe.

Physical limitations (arthritis, missing limbs, blind, deaf, etc.)Yes/No. If Yes, please descibe.

Bloat, cancer, other (describe)Yes/No. If Yes, please descibe.

Last visit to the vet? (routine, illness, or injury)Yes/No. If Yes, please descibe.

Any recent medical issues?Yes/No. If Yes, please descibe.

Any incidents/illnesses in the past month?Yes/No. If Yes, please descibe.

Pet History

Has pet ever bitten a person, pet, or animal?Yes/No. If Yes, please descibe.

Has pet ever been bitten or attacked by another pet?Yes/No. If Yes, please descibe.

Are there any specific behaviors or requirements we need to be aware of?Yes/No. If Yes, please descibe.

Has your pet ever been boarded before? (new clients only)Yes/No. If Yes, please descibe.

Does your pet play well with others?Yes/No. If Yes, please descibe.

Is your pet protective of its food/toys?Yes/No. If Yes, please descibe.

Pet Experiences

What's your pet's behavior when....

8328 162nd Avenue
Orion, Illinois

Monday - Friday:
8:00am - 11:00am &
3:00pm - 5:30pm

Saturday 8:00am - 11:00am

Sunday: Pick up/drop offs 4:00-5:00pm ONLY

309.738.4130