TVH -- New Client Canine Health History

New Client - Canine Health History

Troy Veterinary Hospital
Today's Date/Time
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should another person be listed on account?

First Name Last Name
Secondary Owner's Phone Number

Area Code Phone Number
Email *
example@example.com
When is your appointment? *
Date and Time
Client health screening: please complete this survey prior to coming to our hospitals to inform us of any risk to our team members. We do require face coverings for all clients coming within six feet of our employees.
Please check all that apply so we may take appropriate precautions. *

I have confirmed Covid 19 or am under quarantine for due to exposure risk I have symptoms of illness I have been exposed to Covid 19 through travel to an at risk region I do not have any Covid 19 risk factors at this time.
Pet's name *
My pet:

has seen a veterinarian and I have records has seen a veterinarian but I am unable to access records has not seen a veterinarian I am not sure about history
Birth Date

Month Day Year
Or age of dog if birthday is not known:
Breed: *
Color: *
Sex: *

Spayed Female Intact Female Neutered Male Intact Male Not sure
When was my dog's last dose of their Heartworm Prevention? *
What kind of Heartworm Prevention does my dog take? *
When was my dog's last dose of their Flea and Tick Prevention? *
What kind of Flea and Tick Prevention is my dog on? *
Is your dog on any prescription or homeopathic medications or supplements?
Social Media:
On occasion we like to post pictures or feature patients that we see in our hospital on one of our social media accounts. Our accounts include Facebook, Twitter, and Instagram as well as our website. In order to do so, we need written consent from the owner/agent of the pad. Please initial next to the platform that you would be comfortable having your pet featured on, if you do not want your pet featured on any of these platforms initial next to “I Do Not Consent“.

Facebook: Initials Twitter: Initials Instagram: Initials Our Website: Initials I Do Not Consent: Initials
I hereby authorize the veterinary hospital to examine, prescribe, and treat my pet. I assume financial responsibility for all charges accrued through the treatment of my pets. I understand that payment must be made at the time of treatment and that I may be asked for a deposit for emergency and surgical treament.
Signature *

Clear
My dog's story
My dog joined my family as
My dog lives in a/an
My dog lives with
To me, my dog is: (please check all that apply)

My best friend My walking companion My workout/hiking pal My farm or country dog My working dog My fur kid My kids' dog My couch buddy My service dog My guardian dog My activity/agility partner My constant companion
With people, my dog
With other dogs, my dog
With cats, my dog thinks
Bringing my dog to the vet is
Do you have anything to add about your pet's story?
My dog's exercise and nutrition assessment
My dog is
When my dog is "home alone". s/he is
My dog is outside
For exercise, my dog (check all that apply):

goes out in the yard to do his or her "business". walks on a leash twice or more daily. plays in a fenced in yard. joins me for extended walks and runs. frequently plays with other dogs. participates in active play with people-frisbee, fetch, soccer, etc. participates in intensive training like agility or schutzhund. is a country or farm dog and runs free. is a working dog, and is active with me all day.
For primary nutrition, my dog eats (check all that apply):

a homemade diet. a raw food diet. a high quality commercial dry food. a high quality commercial wet food. a prescription diet. a commercial name brand dry food. a commercial name brand wet food. a store brand dry food. a store brand wet food. only people food.
My dog eats
When it comes to treats, my dog has
For treats, I use (check all that apply)

commercial dog treats in a bag. homemade dog biscuits. marrow or neck bones. stuffed Kongs or marrow bones. fresh or frozen vegetables. doggie ice cream. table scraps and leftovers. cheese or meat bits. jerky treats or other dried bits. rawhide or porkhide.
Is there anything more you would like to add or ask about your dog's exercise and nutrition?
Environmental Risks
My dog and I like to visit (check all that apply)

friends with other pets pet and feed stores farmer's markets and festivals schools and athletic fields obedience/agility/training classes ponds, streams, and woods hiking trails dog competitions therapy dog-schools/hospitals/nursing homes dog parks, boarding, doggy day care
My dog and I like to travel
When we are outside, my dog
Does your dog have any special environmental risks that we should know about?
Health Survey:
Let's start with their mouth:
What about your dog's mouth? (check all that apply)

Looks great with pearly whites seeing some tartar seems to have quite a bit of tartar gums look pink and healthy gums are a bit red and irritated gums are very red and seem sore still has "puppy breath" catch a whiff of bad breath sometimes breath leaves something to be desired ugh! serious doggy breath
What dental care do you do at home? (check all that apply)

uhmmm-not much really use dental chews or treats use water additives brush my dog's teeth on occasion brush my dog's teeth regularly have annual dental scale and polish
And their eyes:
My dog's eyes (check all that apply)

are clear and shiny. have some redness and irritation at times. have a gunky discharge sometimes. are frequently irritated and draining. are getting cloudy. are of concern. My dog is bumping into things.
Ears:
My dog's ears (check all that apply):

seem fine. have some gunk and debris once in awhile. always seem to have some debris. sometimes have a yellow or brown discharge. seem red or swollen on the inside. seem swollen or irritated on the outside. seem itchy. S/he scratches them frequently. are of concern. My dog does not seem to hearing as well as s/he used to.
Heart and Lungs:
My dog (check all that apply)

seems to be fine--no changes noted. seems to cough, sneeze, or gag more that s/he used to. seems to pant more frequently than s/h used to. has changed his or her bark. seems to get out of breath easily. seems to be more anxious, and I feel like his or her heart is beating faster at times.
Skin and Body:
My dog's coat and body (check all that apply)

is shiny and fine. is dull and not as soft as it used to be. is oily and flaky. is dry, and appears to be itchy. seems to have an odor, and I see some crusty skin. has changed this year, and I am seeing some hair loss. has some open sores at times that seem to heal by themselves. has open sores that do not heal. gets little pimples that sometimes open up. has some lumps and bumps. has patches of hardened or thickened skin. is prone to hot spots at certain times of the year.
Mobility and movement:
My dog(check all that apply)

is still running around without a care in the world. seems awkward sometimes and limps once in awhile. is playing hard, but occasionally seems to overdo it. is playing less than s/he used to, but still gets around okay. is slowing down and does not seem as interested in play. is stiff and has difficulty with stairs and climbing. seems to be painful sometimes when moving around.
Weight and appetite:
My dog (check all that apply)

is still at the same weight and eating and drinking as usual. has not gained or lost weight this year. has gained weight this year eating the same amount of food. has gained weight and is eating more. has gained weight but s/he is actually eating less. has lost weight this past year due to diet and exercise changes. has lost weight but is still eating like s/he used to. has lost weight and is eating less. seems to be hungry all the time. seems to be thirsty all the time. is drinking more water than s/he used to. seems to have trouble eating his/her normal food.
GI system:
My dog (check all that apply)

is urinating and defecating as usual. is having trouble controlling his/her bladder is making messes in the house seems to be urinating more frequently. seems to be defecating more frequently. has strong smelling urine. has unusually strong smelling stools. has frequent loose stools. seems to get constipated. seems to get nausea frequently. seems to vomit frequently. eats grass. seems to have a sensitive stomach. frequently gets into stuff s/he should not eat. has a cast iron gut-nothing bothers him or her.
Behavior and Cognition:
My dog (check all that apply)

is acting like the happy pup s/he is. has not had any behavioral changes. has had behavioral problems in the past but they have improved. continues to struggle with behavioral problems (please let us know what these are) is showing some increased anxiety is showing some increased aggression sometimes seems confused is not as responsive to us as s/he used to be is lethargic and sometimes acts depressed
Have there been other health changes that we should be aware of?
What are the primary concerns that need to be addressed at today's visit?
Thank you so much for completing this survey. We appreciate your deep knowledge of your pet, and this helps us partner more effectively with you to develop the best preventive care plan tailored to meet your pet's and your family's needs.
Should be Empty:

New Client - Canine Health History

My dog's story

My dog's exercise and nutrition assessment

Environmental Risks

Health Survey:

Let's start with their mouth:

And their eyes:

Ears:

Heart and Lungs:

Skin and Body:

Mobility and movement:

Weight and appetite:

GI system:

Behavior and Cognition: