Patient History Form

Name

First Last

Phone

Email

Date

Pet's Name

What is the main complaint or symptom your pet is having that you are most concerned about today?

How long ago did you first notice this symptom/problem?

Please indicate if this is a wellness visit, if not leave blank

Please list any other problems or symptoms present at this time

Please briefly describe any major illnesses, surgery or other problems that occurred in the past

Please describe your pet’s diet (specify the brand, canned or dry and the daily amount)

List any current medications and/or supplements

Is your pet on monthly flea/tick and/or heartworm prevention? Which ones?

Pick one of these 5 descriptions that best describes your pet’s personality

Easy going, loves everyone, laid back, easily satisfied, patient, social, slow reaction to strangers
Fearful, quiet, independent, a one person pet, shy, smart, runs away from strangers
Well-behaved, obedient, likes a routine, problem solver, ignores strangers
Dominant, very active, moves fast, competitive, stubborn, barks at strangers
Excitable, hard to calm down, likes to be center of attention, mischievous, wags tail at strangers

If this is a follow up visit, describe what has changed since last treatment; list what has improved and what has deteriorated

Please check all boxes below that apply to your pet: