Patient History Form- Sick

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
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?
Please list current medications and supplements:
Is your pet up to take 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?
If there is anything else you would like us to know, please include below:
Should be Empty:

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