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
*
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Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
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?
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