Medical Concern Patient History

"*" indicates required fields

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.

Name*

First

Last

Email*

Appointment Date/Time*

It is imperative that we be able to reach you in a timely manner while your pet is in the building. Please have your cell phone listed below available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

Phone*

Pet Information

Pet's Name*

Pet's Age*

Species*

Canine (Dog)

Feline (Cat)

Other

If other, please specify*

Breed*

Reason for your pet's visit today?*

How long has this been going on?*

This issue is*

Improving

Continuing (stable or unchanging)

Worsening

Has your pet had any*

Coughing

Sneezing

Vomiting

Diarrhea

Has your pet had any

New lumps or bumps

Behavior changes

Changes in mobility

My pet's appetite is*

Normal

Increased

Decreased

Location of Lumps/Bumps

When did you notice them?

Any discharge or odor from bumps?

Please Describe Behavior Changes

Please Describe Mobility Changes

If increased or decreased, please provide more information

My pet's thirst level is*

Normal

Increased

Decreased

If increased or decreased, please explain

My pet's activity level is*

Normal

Increased

Decreased (lethargic)

If increased or decreased, please explain

My pet's urination is*

Normal

Abnormal

Color

Amount

Frequency

Duration of Abnormal Urination

My pet eats (choose all that apply)*

Wet food only

Dry food only

Wet and dry mixture

People food

Raw diet

Home Cooked Diet

Other

If Other, please explain

Brand of pet food*

If prescription diet, what formulation?*

How often is your pet fed?*

How much is your pet fed?*

In addition to pet food, what treats or other food does your pet receive?*

Include any human food, veterinary dental products, bones, rawhides, etc

Has your pet's diet changed in the last 6 months?*

Yes

I am not sure

Is it possible for your pet to have*

Eaten garbage

Ingested toxins (rat bait, ant bait, etc)

Ingested mushrooms

Ingested marijuana

Eaten toys (part of toys missing, chewed up, etc)

Eaten grain free diet for any period of time

Ingested human or animal medications not intended for them or at higher doses than intended?

None of the above are possible

Other

If other, please explain

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given*

Additional Information

What kind of heartworm preventative do you use?*

Name of medication – put unknown if not sure

When was your pet's last dose of heartworm preventative?*

Date given (please type N/A if not on a preventative)

What kind of flea/tick preventative do you use?*

Name of medication – put unknown if not sure

When was your pet's last dose of flea/tick preventative?*

Date given (please type N/A if not on a preventative)

Is your pet?*

Indoor only

Mostly indoor but rarely goes outside

Indoor/Outdoor

Outdoor only

Outdoor during day/inside at night

Other

If Other, please explain

Are there other pets in your home?*

Yes

Farm Animals

Please tell us about the other pet's in your home

Does your pet?*

Visit the dog park

Get groomed regularly

Compete in Dog/Cat shows

Attend obedience training

Attend Agility/Dock Diving/Search and Rescue programs, etc

Board

Attend Doggie Daycare

Other

If Other, please explain

Is your pet current on vaccinations?*

Yes

I am not sure

My pet's vaccines were administered last by*

At this Companion Animal Hospital

I am not sure where

Other

If Other, please state where

Does your pet have a microchip?*

Yes

I am not sure

Has your pet bitten anyone in the last 10 days?*

Yes

I am not sure

Does your pet have known health concerns and/or chronic disease or conditions?*

If yes, please tell us more. If no, please note N/A

Is there anything else we should know about your pet?*

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Please upload if available

Is there anything else you would like to discuss during your appointment?

Appointment Procedures

I understand that payment is due, in full, at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account and/or by phone.*

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Signature*

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Pet Information

Additional Information

Appointment Procedures

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