Medical Concern Patient History Form

"*" indicates required fields

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

Owner Information

First Name*

Last Name*

Appointment Date/Time*

What phone number can we call you at while your pet is here?*

Pet Information

Pet Name*

Pet Age*

Species*

Cat

Dog

Other

Breed*

If other, please specify*

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

Location of Lumps/Bumps*

When did you notice them?*

Any discharge or odor from bumps?*

Please Describe Changes*

My pet's appetite is*

If increased or decreased, please provide more information*

My pet's thirst level is*

If increased or decreased, please provide more information*

My pet's activity level is*

If increased or decreased, please provide more information*

My pet's urination is*

Color*

Amount*

Frequency*

Duration of Abnormal Urination*

My pet eats*

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, other known toxic substances)

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

Please tell us more*

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

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 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 preventative)

Is your pet?*

Indoor Only

Mostly Indoor but Rarely to Occasionally Spends Time Outdoors

Indoor/Outdoor

Outdoor Only

Outdoor During Day/Inside At Night

Other

If other, please explain*

Are there other pets in the home?*

Yes

Farm Animals

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

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

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 specify*

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?

Max. file size: 50 MB.

Please upload if available

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

Appointment Procedures

As of January 2023, we are now doing in-person appointments. Masks are required upon entry.

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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