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Hours 1830 Polk Street
San Francisco, CA 94109

Appointment Questionnaire

Pet's Name:*

Date and Time of Appt:*

What is the reason for today’s visit?*

If your pet is ill, when did the symptoms start?*

Any excessive sneezing or coughing?*

Any vomiting, diarrhea or constipation; if so how often?*

Are there any changes in appetite?*

Any changes in drinking/urinating (i.e. drinking or urinating excessively, trouble urinating, etc)? If so, please explain:*

Any changes in pet’s energy level?*

Please list any historical or ongoing medical problems:

Dogs Only

My dog goes (check all that apply):

To Dog Parks

To Daycare

To Boarding

To the Groomer

Hiking or Camping

Cats Only

My cat...(check one):

Only stays indoors

Goes outdoors

Other pets in household:

What brand and type of food are you feeding your pet? How much and how often?*

Is your pet taking flea/tick/heartworm prevention? If so, which brand(s)?*

Please list any other current medications and supplements.*

Do you require medication refills?*

Travel history (outside of San Francisco):*

Additional Relevant Information:

Polk Street Animal Hospital