Patient Admitting Form Client’s Name* First Last Patient Name*Species*DogCatWhat concerns you about your pet today?*How long has this problem been going on?*Are there any other problems?*YesNoPast Pertinent History*General Appearance / Attitude*Any Behavior Issues?*YesNoAny Allergies (that you know of?)*YesNoAny history of seizurs?*YesNoAny past surgeries?*YesNoIs your pet:*IndoorOutdoorBothDoes your pet have any access or exposure to open space? Tick exposure?*YesNoAny potential exposure to toxins (insecticides, poisons, antifreeze?)*YesNoIs there any vomiting*YesNoIf yes, for how long?Is there any diarrhea*YesNoIf yes, for how long?Is there any coughing*YesNoIf yes, for how long?Is there any sneezing*YesNoIf yes, for how long?Is your pet eating*YesNoIs your pet drinking*YesNoIs your pet urinating normally*YesNoIf not, for how long?Bowel movements normal?*YesNoIf not, for how long?Is cat using litter box appropriately?*YesNoWhat kind of litter do you use?*What is your pet’s diet including name brand and how much do you feed per day? Grain Free Diet?*Is your pet currently taking any medication?*YesNoIf yes, what medication and dosageWas medication given today?*YesNoTimeIs your pet on consistent flea control?*YesNoIf yes, which one?Is your pet micro chipped?*YesNoIs your pet spayed or neutered or no?*YesNoIs your pet current on its rabies vaccination?*YesNoOther vaccinations?*YesNoAny history of vaccine reactions?*YesNoIf yes, describe the reaction and when it happened?Has your pet had a fecal analysis in the last 6 months?*YesNoIs your pet on consistent heartworm prevention?*YesNoIf yes, which one?Are there other pets at home?*YesNoIf yes, what kindDog(s)Cat(s)In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked.*Alternate #Signature*Date* PhoneThis field is for validation purposes and should be left unchanged.
