Canine/Feline History Form
Date Of Your Appointment
Does your pet go outside at all?
Yes on leash only
Yes off leash but supervised
Yes off leash unsupervised
How is your pet's appetite?
Have you noticed any of the following in your pet:
Straining to defecate
Straining to urinate
Urinating in inappropriate places
Defecating in inappropriate places
Limping or stiffness
Lumps or growths
Reduced energy or lethargy
Itchiness or skin rash/lesions
Head shaking or scratching at ears
Does your pet have any allergy or intolerance that you know of?
Has your pet ever had a reaction to a vaccine or medication?
Does your pet have any illnesses?
Is your pet currently taking any medications, vitamins, supplements? Please list them.
What is your pet currently eating? List all food, treats and chews.
Does your pet live with other pets? Please list species and number of the other pets.
Does your pet have contacts with any animals outside of your household?
Do you have any concerns about your pet?
Pet Health Insurance can help pet owners provide the best health care for their pets by mitigating cost concerns. Pets + Us offers a free, no obligation 6 weeks insurance trial for pets aged 7 weeks to 8 years. For more information on Pets + Us you can go to petsplusus.com. Would you like a free trial for your pet (please note that pre-existing conditions are not covered by insurances)?
My pet is not eligible
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