Chippens Hill Veterinary Hospital Patient History Form

Chippens Hill Veterinary Hospital Patient History - Wellness
Thank you for giving us the opportunity to care for your pet. To help us understand how your pet is feeling, please complete the following form entirely.
Client Name

First NameLast Name
Cellphone Number (we will need to reach you to discuss your pet's exam)*

Area CodePhone Number
Email*
example@example.com
Do we have permission to send vaccine and appointment reminders to your e-mail address?

YesNo
Please let us know your preferred method of contact.
Pet Insurance Provider
Please provide the followng information for you pet:

Rows

NAME

DOG OR CAT
Does your pet have any of the following? (please select all that apply)

CoughingSneezingVomitingDiarrhea
If you answered yes above, please describe.
Has your pet had any changes in mobility or activity level? If so, please describe.
Has your pet had any head shaking, licking or scratching? If so, please describe.
Has your pet had any changes in eating or drinking habits? If so, please describe.
Does your pet have any lumps, bumps or hair loss? If so, please describe.
What date was the last dose of flea/tick prevention?

MonthDayYear
Date
What date was the last dose of heart worm prevention?

MonthDayYear
Date
Please describe your pet's food and treats. Please let us know whether there have been recent changes or additions.
Does your pet go to a grooming, boarding or day care facility? If so, please describe.
Please check all that apply to your pet's exercise:

100% IndoorsWalks on leashLoose in a fenced yardDoggy day careOff-leash dog parksOther
If you indicated Other for your pet's exercise, please describe here:
Does your pet go to competition? If so, please describe.
For our kitty friends - does your cat go outside?

Strictly IndoorsIndoor/OutdoorOutdoor OnlySometimes goes in the yard
Would you like us to express your pet's anal glands?

YESNO
Would you like us to trim your pet's nails?

YESNO
Would you like us to clip off any mats? If so, please describe where they are:
If your female pet is not spayed, when was she last in heat?

MonthDayYear
Date
Do you have any concerns for the veterinarian to address?
Should be Empty:

Rows
NAME
DOG OR CAT

Chippens Hill Veterinary Hospital Patient History - Wellness