Patient History Form Client's Name:*What is your pet's name:*Species*Is this a recheck appointment?* Yes No What concerns you about your pet today?*How long has this problem been going on?*Are there any other problems?* Yes No Past History:*General Appearance / Attitude*Any Behavior Issues?* Yes No Explain Below:*Any Allergies (that you know of?)* Yes No Explain Below:*Any history of seizures?* Yes No Explain Below:*Any past surgeries?* Yes No Explain Below:*Is your pet Indoor? Outdoor? Both?* Indoor Outdoor Both Does your pet have any access or exposure to open space? Tick exposure?* Yes No Any potential exposure to toxins (insecticides, poisons, antifreeze?)* Yes No Is there any vomiting?* Yes No How Long?*Is there any diarrhea?* Yes No Is there any coughing?* Yes No How Long?*Is there any sneezing?* Yes No Is your pet eating?* Yes No Is your pet drinking?* Yes No Is your pet urinating normally?* Yes No For how long has this been an issue?*Bowel movements normal?* Yes No For how long has this been an issue?*If your patient is a cat, Is cat using litter box appropriately?* Yes No N/a If your patient uses a litter box, what kind of litter do you use?*Please say "N/A" if not applicableWhat 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?* Yes No What medication and dosage are you giving? Please list at home medication routine for the Doctor to review. BE SPECIFIC!*Was the medication given today?*Is your pet on consistent flea control?* Yes No Is your pet micro chipped?* Yes No Is your pet spayed or neutered or no?* Yes No Is your pet current on its rabies vaccination?* Yes No Other vaccinations?* Yes No Any history of vaccine reactions?* Yes No Please Explain*Has your pet had a fecal analysis in the last 6 months?* Yes No Is your pet on consistent heartworm prevention?* Yes No What brand of flea prevention do you use?*What brand of tick prevention do you use?*What brand of heartworm prevention do you use?*Are there other pets at home?* Yes No What kind?*What insurance provider do you have for your pet?*I authorize Martinez Animal Hospital to charge up to this amount in case I am unavailable for contact*Please enter maximum $ valueIn 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*LATE ARRIVAL POLICY* I agree to the late arrival to appointment policy.IF YOU ARE 10+ MINUTES LATE TO YOUR APPOINTMENT, IT IS UP TO OUR DISCRETION IF WE CAN STILL TAKE YOUR APPOINTMENT. A $10 LATE ARRIVAL FEE WILL APPLY.CANCELLATION/NO SHOW POLICY* I agree to the cancellation/ no show policy.WE REQUIRE 24 HOUR NOTICE FOR RESCHEDULING AND CANCELLING APPOINTMENTS. IF YOU DO NOT PROVIDE US 24 HOUR NOTICE, YOU WILL BE CHARGED A MISSED APPOINTMENT FEE.Signature*Date MM slash DD slash YYYY Consent I agree to the privacy policy.
