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Patient History Form
Name
First
Last
Phone
Email
Date
Date Format: MM slash DD slash YYYY
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
This is a wellness visit and I do not have any concerns about my pet
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:
Decreased appetite
Increased appetite
Constipation
Decreased thirst
Increased thirst
Lumps on body
Urinary Incontinence
Itchy skin
Smelly ears/discharge
Back pain
Limping
Weight loss
Coughing
Sneezing
Vomiting
Diarrhea
Vision problems
Hearing problems
Fatigue/lethargy
Bad breath
Dry skin
Greasy/smelly skin
Painful
Pants at rest
Restless
Bleeding
Blood in stool or urine
Behavioral problems
About Us
Location & Hours
Our Team
Make An Appointment
Patient History Form
Pet Services
Anesthesia and Patient Monitoring
Avian Medicine and Surgery
Exotic Pet Medicine and Surgery
Medical Services
Nutritional Counseling
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Additional Services
My Pet
Links
Interactive Animal
Breed Info
Videos
Pet Health Checker
Pharmacy