Exam History Form

Patient History Form

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.
Pet's name *

First Name Last Name
Pet's Name *
Who is your pet seeing today?
Your name *

First Name Last Name
Email
example@example.com
It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.
Where can we call you at while your pet is here? *

Area Code Phone Number
Have you or your pet traveled outside of Washington state in the last 14 days? *

Yes No
Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days? *

Yes No
Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days? *

Yes No
Reason for your pet's visit today? *
This issue began on: *
Date
Has your pet had any: *

Coughing Sneezing Vomiting Diarrhea Seizures My pet has NOT had any coughing, sneezing, vomiting or diarrhea
Color
Texture
Frequency
Consistency
Duration
Blood present?

Yes No
Is the cough productive?

Yes No I'm not sure
Is there mucous present?

Yes No I'm not sure
Color
Is it possible for your pet to have:

Eaten garbage Ingested toxins (rat bait, ant bait, other known toxic substances) Ingested Mushrooms Ingested Marijuana Eaten toys (part of toys missing, chewed up etc.) Eaten grain free diet for any period of time Ingested human or animal medications not intended for them or at higher doses than intended? It is not possible for my pet to have eaten garbage; ingested toxins, mushrooms, marijuana or toys; eaten a grain free diet; or ingested human/animal medications not intended for them or at higher doses than intended.
Please tell us more:
Has your pet had any: *

New lumps or bumps Behavior changes Changes in mobility My pet has not had any new lumps/bumps; behavior changes; or changes in mobility.
Please Describe Changes
Location of Lumps/Bumps
When Did You Notice Them?
Any Discharge or Odor from Bumps?
My pet's appetite is: *
If increased or decreased, please provide more information:
My pet's thirst level is: *
If increased or decreased, please provide more information:
My pet's activity level is: *
If increased or decreased, please provide more information:
My pet's urination is: *
Color
Amount
Frequency
Duration of Abnormal Urination
My pet eats *

Wet food only Dry food only Wet and Dry Mixture People Food Raw Diet Home Cooked Diet
Brand of Pet Food *
If prescription diet, what formulation? *
How Often Is Your Pet Fed? *
How Much Is Your Pet Fed? *
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.) *
Has your pet's diet changed in the last 6 months? *

Yes No I am not sure
When Was Your Pet's Last Dose of Heartworm Preventative? *
Date Given (Please type N/A if not on a preventative)
What Kind of Heartworm Preventative Do You Use? *
Name of medication - put unknown if not sure
When Was Your Pet's Last Dose of Flea/Tick Preventative? *
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use? *
Name of medication - put unknown if not sure
Please list any medications, supplements, topical treatments your pet has received in the past month that are NOT listed above and tell us when they were last given: *
If none, please type "N/A"
Is Your Pet: *

Indoor Only Mostly Indoor but Rarely to Occasionally Spends Time Outdoors Indoor/Outdoor Outdoor Only Outdoor During Day/Inside At Night
Are There Other Pets In The Home *

Yes No
Please tell us about the other pet(s) in your home
Does Your Pet: *

Visit the dog park Attend Doggie Daycare Board or Kennel Get Groomed Regularly Attend Obedience Training Attend Agility/Dock Diving/Search and Rescue programs etc. Compete in Dog/Cat Shows Travel with you (inside Washington state) Travel with you (outside Washington state) NONE OF THE ABOVE
Is Your Pet Current On Vaccinations? *

Yes No I Am Not Sure
My pet's vaccines were administered last by: *

At Poulsbo Marina Veterinary Clinic I Am Not Sure Where
Does Your Pet Have A Microchip? *

Yes No I Am Not Sure
Has Your Pet Bitten Anyone In the Last 15 Days? *

Yes No I Am Not Sure
Are there pictures or video that would help us with our exam today?

Browse Files
Please upload if available. Cancel of
Please Tell Us More About Your Pet's Health Conc
If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Is There Anything Else You Would Like To Discuss Today?
Appointment Procedures
I understand I should remain in my vehicle at all times while on Poulsbo Marina Veterinary Clinic grounds. This is for your safety and the safety of our clients and patients *
Initial
I understand that access to the Poulsbo Marina Veterinary Clinic building is limited to employees only at this time. *
Initial
I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone. *
Initial
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Patient History Form

Appointment Procedures