East Holland Veterinary Clinic- Annual Wellness History

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 Hour Minutes 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?
Should be Empty:

East Holland Veterinary Clinic

Owner Contact Information

Pet Information- Required History

Appointment Information