East Holland Veterinary Clinic
Annual Wellness History
Owner Contact Information
First Name
*
Last Name
*
Telephone number
*
What # can we reach you at during the appointment?
Pet Information- Required History
Pets Name
*
Does your pet take any medications or Over the Counter supplements?
*
Yes, Please list below
No
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% (Outdoor 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
Appointment Information
Appointment Date
*
-
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
Reason for visit: Check all that apply
*
Annual Physical Exam
Vaccinations
Heartworm Testing
Fecal/Intestinal Parasite screen
Puppy/Kitten visit
Labwork
Technician Appt: Nail Trim, Anal glands, Allergy inj, etc.
What flea/tick/heartworm prevention is your pet currently taking?
*
Interceptor Plus
Heartgard Plus
ProHeart6 (6 month injectable heartworm prevention for dogs)
ProHeart12 (12 month injectable heartworm prevention for dogs)
Credelio
Vectra 3D
Frontline
Please refill my pets heartworm or flea prevention
*
Yes
No
Qty Requested today
*
My pets diet consists of
*
Are there any concerns for the following; (check all that apply)
*
Appetite Change
Changes in drinking
Weight Gain
Weight Loss
Itching/Scratching
Shaking Head
Bad Breath
Vomiting
Changes in stool
Changes in urination
Excessive sleeping
Scooting
Difficulty getting up
Skin Masses (explain below)
Behavioral concerns (explain below)
Changes in activity
Limping
Hairloss
Coughing
None
If there are concerns, how long has your pet been experiencing this problem?
Has your pet ever experienced an adverse reaction to any vaccinations, medications or other procedures?
*
Yes
No
Do you need any refills of other medication or food? Please list below.
*
Yes
No
Any additional information you feel would be helpful for the doctor?
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