Patient History Form

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

If Yes, how long?

Vomiting
 Yes
 No

If Yes, how long?

Diarrhea
 Yes
 No

If Yes, how long?

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:

Administered on:

How often?

Is your pet taking any other medications?

Questions or concerns?

Please initial here

Signature will be required upon check-in


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