Patient History Form Client's Name:*Patient Name:*Species*Is this a recheck appointment?*YesNoWhat concerns you about your pet today?*How long has this problem been going on?*Are there any other problems?*YesNoPast History:*General Appearance / Attitude*Any Behavior Issues?*YesNoExplain Below:*Any Allergies (that you know of?)*YesNoExplain Below:*Any history of seizures?*YesNoExplain Below:*Any past surgeries?*YesNoExplain Below:*Is your pet Indoor? Outdoor? Both?*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?*YesNoHow Long?*Is there any diarrhea?*YesNoIs there any coughing?*YesNoHow Long?*Is there any sneezing?*YesNoIs your pet eating?*YesNoIs your pet drinking?*YesNoIs your pet urinating normally?*YesNoFor how long has this been an issue?*Bowel movements normal?*YesNoFor how long has this been an issue?*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?*YesNoWhat Medication and Dosage?*Was the medication given today?*Is your pet on consistent flea control?*YesNoIs 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?*YesNoPlease Explain*Has your pet had a fecal analysis in the last 6 months?*YesNoIs your pet on consistent heartworm prevention?*YesNoWhat brand of flea/tick/heartworm prevention do you use?*Are there other pets at home?*YesNoWhat kind?*What insurance provider do you have for your pet?*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 Phone*Signature*Date
