Revelstoke Veterinary Clinic Patient History Form

PATIENT HISTORY

Please complete to the best of your ability -- it helps us help your pet
Patient Name: *
Species: *

Canine Feline Equine
Breed:
Age:
Client Name: *
Please include alternate last name if you are co-owner
Date: *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Client Email: *
Reason for appointment: *
If appropriate, which Feline vaccines would you like administered today. Check all that apply

FVRCP (distemper for cats) Rabies None - please do not vaccinate
If appropriate, which Canine vaccines would you like administered today. Check all that apply

DAPPV (distemper) Rabies Bordetella (Kennel Cough) None - please do not vaccinate
DIET
What diet are you currently feeding your pet? *
How much are you feeding on a daily basis?
Any change in appetite

Increased appetite Decreased appetite Normal appetite
Please elaborate on appetite change.
Have you made any recent changes to your pet's diet?

Yes No
Please elaborate on diet changes.
Please list any treats and human food given in addition to the regular diet.
VOMITING - DIARRHEA
Is your pet currently experiencing: *

Vomit Diarrhea Both No vomit or diarrhea
Any blood in Vomit or Diarrhea?

Yes No
Please indicate when issue started, frequency, etc.
Please describe any dietary indiscretion such as treats, garbage, toxin ingestion etc you think may be related to the vomiting/diarrhea.
What have you done to try to control the vomiting/diarrhea? Did it help?
DRINKING AND URINATION
Have you noted: *

Excessive thirst Reduced thirst Normal water consumption
Have you noted any of the following, (check all that apply):

increased frequency of urination increased volume of urination blood in urine pain while urinating Inability to urinate Unsure, urination is not witnessed Urinating in the house/outside of litter box
Please elaborate
RESPIRATORY
Is your pet coughing or sneezing? *

Yes No
Is there any nasal discharge

Yes No
Has your pet been at a kennel, groomer or around other coughing dogs?

Yes No
Please give details. When was exposed etc
Is he/she breathing more quickly or with increased effort?

Yes No
Please describe
SKIN AND COAT
Have you noted any of the following, (check all that apply):

Lumps Wounds Rash Itch Fleas or Ticks No concerns with skin or coat Other
Please describe location, when first noticed, if painful and if any change since noting.
Please describe including: location of itch - how long it has been present -what treatments have been tried - if treatments have helped
Is your pet receiving a parasite control product?

Yes No Not recently
Please indicate which product and when was the last dose was given.
VISION/HEARING
Is your pet experiencing eye discomfort, including discharge, excessive tearing and/or redness in eyes?

Yes No
Which eye(s)?

Left Right Both
Have you noticed any vision loss?

Yes No
Have you noticed any hearing loss?

Yes No Selective hearing
Please explain
MOBILITY ISSUES
Is your pet limping or experiencing any pain or difficulty walking, running or standing? Please check all that apply.

No Mild Moderate Severe Only after exercise Related to a recent injury or event.
Which legs are affected?
Please elaborate
TRAVEL HISTORY OR PLANNED TRAVEL
List areas within Canada or abroad where your pet has travelled in the last six months.
List areas within Canada you are planning to travel with your pet in the next six months.
Will your pet be spending time in a boarding kennel in the next 6-12 months.

Yes No
Will your pet be leaving the country in the next 6-12 months.

Yes No
What country will they be travelling to?
MEDICATIONS OR SUPPLEMENTS
What medication, supplements or preventatives is your pet currently receiving? - Please indicate strength, frequency and when last dose was given.
Please indicate any previous medication or vaccine reactions.
BEHAVIOUR CONCERNS
Please describe any behaviour concerns (for example aggression, urinating outside litter box, etc)
Have you noticed any recent change in activity level

Increased energy and activity level Decreased energy and activity level Normal energy and activity level
Please describe any new or unusual behaviour your pet is exhibiting.
Has your pet been aggressive or overly anxious in a veterinary clinic in the past? *

No Yes
Please explain, including what has been tried or found effective/ineffective in reducing their anxiety or aggression?
OTHER CONCERNS
Please list any other concerns or requests
Do you have pet insurance: *

Yes No
Company Name and Policy Number
ARE YOU OR ANYONE IN YOUR HOUSEHOLD EXHIBITING ANY SYMPTOMS POSSIBLY CONSISTENT WITH COVID-19 INFECTION? YES or NO *
PLEASE NOTE -- IF YES, WE ASSURE YOU WE WILL ATTEND TO YOUR PET, BUT WE MUST KNOW SO THAT WE CAN TAKE NECESSARY PRECAUTIONS
Signature *

Clear
Should be Empty:

PATIENT HISTORY

DIET

VOMITING - DIARRHEA

DRINKING AND URINATION

RESPIRATORY

SKIN AND COAT

VISION/HEARING

MOBILITY ISSUES

TRAVEL HISTORY OR PLANNED TRAVEL

MEDICATIONS OR SUPPLEMENTS

BEHAVIOUR CONCERNS

OTHER CONCERNS