Pre-Visit History Form

Pet's Medical History

Pre-Visit Form
Your Full Name *

First Name Last Name
What is the date of your appointment?

Month Day Year
Date
Who is your pet's appointment with? *
Your Pet's Name *
Please confirm your email address *
example@example.com
Cell Phone Number *

Area Code Phone Number
Please select your pet's reason for visiting us: *
Is your pet experiencing any of the following (check as many as apply): *

Lethargy (Sluggish) Weight Loss or Trouble Eating Vomiting or Diarrhea Respiratory Concerns Lameness or Difficulty Moving Around Behavior Concerns Not Experiencing Any Known Medical Concerns
Please describe further any other concerns you would like the doctor to know about. If no concerns, type n/c. *
Does your pet typically like or dislike his/her visit with us? *

Loves coming in! Hesitant but ok. Hates the car ride more. Experiences mild signs of anxiety. Experiences moderate signs of anxiety. Typically needs sedation.
Is your pet currently taking any medication? Please also include any Supplements, Heartworm/Flea/Tick medications. *

Yes No
If so, please list the medications he/she is taking. Include dosing information (how much/how often).
When was the last dose of Heartworm and Flea/Tick Prevention given?
Do you require any refills? We recommend that you double check before your appointment.

Yes No
What BRAND of food does your pet eat? Please be specific. *
What type of food does your pet eat? *
How many times a day do you feed your pet? *
How much does your pet eat at each feeding? Please be specific (cups, cans, etc.) *
What additional treats, snacks, or human food does your pet receive. Please be specific and indicate frequency. *
Has your pet's environment changed at all? This includes the addition of new pets, boarding/grooming/training, travel, etc.

Yes No
What is your pet's primary environment? *
To make your pet's visit more positive, we offer food rewards such as treats, canned food or cheese, and peanut butter. Please select from the following: *
Should be Empty:

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Pet's Medical History