Patient History Form
Your Name:
Phone Number:
Pet Name:
Home Care
Does your pet spend time:
Indoors Outdoors Both
Does your Pet have Microchip?
Yes No Unsure
What brand of food does your pet eat?
How much does your pet eat? Amount:
Frequency Once a Day Twice a Day Others
Dental Care provided at home? How often? Brushing Dental Chews Mouth Rinse Water Additive Other
Medical History
Has your pet exhibited any of the following symptoms? If yes, how long have these symptoms persisted?
Coughing Yes No
If Yes, how long?
Sneezing Yes No
Vomiting Yes No
Diarrhea Yes No
What other symptoms has your pet exhibited?
Have you noticed any changes in your pet‘s behavior or eating and drinking habits? If so, please explain.
Does your pet have any ongoing medical conditions (e.g. seizures, allergies, limping, masses/tumors, etc.)? Please include dates and specific locations on the body if applicable.
Medication
Please fill out with as much detail as possible or write n/a if no medications apply. List recently discontinued medications as well.
Heartworm preventive:
Administered on:
How often?
Flea and tick preventive:
Is your pet taking any other medications?
Questions or concerns?
Please initial here
Signature will be required upon check-in
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