East Holland Veterinary Clinic- Injury/Illness pet history form

East Holland Veterinary Clinic

Injury/Illness Pet History Form
Owner Contact Information
First Name *
Last Name *
Telephone number *
What # can we reach you at during the appointment?
Vehicle Information
What color and make of vehicle can we find your pet in?
Appointment Information
Appointment Date *

Month Day Year
Date Hour Minutes AM/PM Option
Pet Information- Required History
What percentage of time does your pet spend outside? *

0% (Only goes outside to use the bathroom) 50% (Enjoys spending majority of day outside but lives indoors) 100% (Outdoors only)
Have you seen any fleas or ticks on your pet *

Yes No
Does your pet come into contact with other animals not in your home? Please check all that apply* *

None Boarding Grooming Dog Parks Other
What is the reason for your visit today? *

Shaking Head Scratching/Itching Bad Breath Vomiting Diarrhea Changes in urination Excessive Sleeping Scooting Difficulty getting up Skin Masses (explain below) Behavioral concerns (explain below) Changes in activity Limping Coughing/Sneezing Eye discharge Seizures
When did you start noticing the problem? *
Has your pet had this problem before? *

Yes No
Did you give your pet any medications or treatments for this problem? If yes, please list. *

Yes No
Any changes in your pets eating or drinking habits? *
What is your pet's typical diet? ( Brand of food) *
Has your pet ever had any adverse reaction to any medications, vaccinations, or other procedure? If so please explain *

Yes No
Any additional information you feel would be helpful for the doctor?
Should be Empty:

East Holland Veterinary Clinic

Owner Contact Information

Appointment Information

Pet Information- Required History