Returning Patient Exam History Form

Returning Patient History Form

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care. These questions are asked prior to every exam.
Pet's name:*

First NameLast Name
Reason for your pet's visit today?

Wellness visit and/or vaccinesSick examOther
This issue began on:
Date
Has your pet had any:*

CoughingSneezingVomitingDiarrheaSeizuresMy pet has NOT had any coughing, sneezing, vomiting or diarrhea
Please tell us more:
Is the cough productive? Is the diarrhea consistent? Is your pet vomiting up food or bile/saliva?
Has your pet had any:*

New lumps or bumpsBehavior changesChanges in mobilityMy pet has not had any new lumps/bumps; behavior changes; or changes in mobility.
Please Describe Changes
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:*
Please list abnormalities:
What brand/type of food does your pet eat? *
Please specify type/variation/protein (i.e. Purina Pro Plan Sensitive Skin and Stomach, NutriSource adult Chicken and Rice, Iams Large Puppy, etc)
Is this food grain free?

Yes, this food is grain free.No, this food is not grain free.I am not sure.
How much and how often is your pet fed?*
If your pet is not fed on a meal schedule (bowl is always full), please type "free-feed"
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)
Is Your Pet:*

Indoor OnlyIndoor/OutdoorOutdoor OnlyOther
Are There Other Pets In The Home*

YesNo
Does Your Pet:*

Visit the dog park or attend "doggie daycare"Board, kennel, or get groomed regularlyAttend Agility/Dock Diving/Search and Rescue programs etc.Compete in Dog/Cat ShowsTravel with you in and out of stateNONE OF THE ABOVE
Please list any medications (prescription and OTC) your pet regularly takes or has received in the past month and tell us when they were last given:
If you are able, please note dosage given. If no medications are given, please type "N/A"
Is your pet on any type of parasite (i.e. flea/tick/heartworm) preventative?
If yes, please state type of preventative and last dose given. If none, please type "N/A".
To the best of your knowledge, has your pet ever had a reaction to any vaccine?

No, my pet has not had a reaction to any vaccine given in the pastYes, my pet has experienced a reaction to a vaccination given in the pastUnknown -- my pet has not yet been previously vaccinated
What reaction(s) has your pet had to past vaccine(s)?

LethargySoreness or swelling at vaccine siteVomiting/diarrheaTrouble breathing and/or seizures
Are there pictures or video that would help us with our exam today?

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Is there anything else you would like to discuss with the doctor today, or that you would like us to know about your pet?
Should be Empty:

Returning Patient History Form