Patient History Form
Client Name
First Name
Last Name
Patient Name
Email
example@example.com
Phone number to reach you at time of appointment
-
Area Code
Phone Number
Has your address/phone number changed?
No
Yes(if yes please add below)
Please enter new address/phone number(s) below
Date of Appointment
-
Month
-
Day
Year
Date
What is the primary reason for your visit today?
When did the symptoms start?
What is your pet's current diet?
Would you like an estimate for today's appointment?
No
Yes
Please list current medications and supplements:
Is your pet up to date on vaccinations?
Is your pet experiencing any of the following?
Decrease in appetite
Decrease in water intake
Diarrhea
Blood in stool
Constipation
Vomiting
Limping
Pain
Difficulty jumping
Urinary accidents
Increased thirst
Increased frequency of urination
Lethargy
Scratching ears or shaking head
Itching
Licking paws
Weight gain
Weight loss
Cough
Sneeze
Discharge from eyes
Discharge from nose
Labored breathing
Bad breath
Drooling
Lumps
Any allergies to food or medications?
Last dose of heartworm and flea/tick prevention? Please include brand (ie Heartgard, Nexgard)
Prior illness/surgeries:
Do you need any Heartworm preventative, Flea/tick preventative or medication or food refilled? If so, how much?
Do you have any concerns about getting your pet to our office or concerns about your pet's stress level during their visit?
If there is anything else you would like us to know, please include below:
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COVID 19 RELATED ILLNESSES
If you or any member of your household experiencing any symptoms of Covid or have tested positive within the last 5 days, please reschedule your appointment or have someone else bring your pet in.
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