Patient History Form Owner's Name:Pet Name:Date Describe any past pertinent history for your pet (fill in):Is your pet …(check one, if applies): Spayed NeuteredIs your pet eating and drinking normally? Yes NoExplain any concerns below:Is your pet experiencing any of the following? Coughing Sneezing Vomiting DiarrheaExplain below:Is your pet urinating and defecating normally? Yes NoExplain any bowel habitsCATS only -- Is your pet using the litter box appropriately? Yes NoExplain below:How is your pet’s appetite and what brand/type food are you feeding?Explain your pet’s lifestyle. Is indoor only, indoor/outdoor, and does it have access/exposure to open space and potential exposure to ticks?How is your pet’s general appearance and attitude? Do you have any concerns?Are you using flea/tick prevention? Yes NoFill in brand of prevention product you are using and how often:Are you using heartworm prevention? Yes NoFill in brand of prevention product you are using:List any medication(s) your pet is taking:Is your pet current on vaccines and has it had any vaccine reactions? Yes NoExplain any past reactions or concerns you have:Does your pet have a microchip? (check one): Yes NoDoes your pet have any behavioral issues? Yes NoExplain any issues or concerns you have:Are there any other pets in your household? Yes NoFill in which species and how many:Do you have pet insurance? Yes NoFill in the name & type of insurance you carry:Does your pet have any allergies? Yes NoFill in all allergens:What is your current concern and reason for your visit today?
