Exam history

Please have all dogs on a leash and collar - tight enough that it does not slip off over the dogs head. Please have all cats in a secure pet carrier with a latching door that is not loose or broken. This is for the safety of your pet as we are located on a busy road and do not want to risk any injury to a loose pet.

Patient Name *

Owner Name

Best Phone # during Appointment

Age

Major Problems- Appointment Scheduled for: (coughing, vomiting, limping, vaccines, etc)

Medications and doses pet is currently taking - please also include supplements

Diet - Type(wet,dry) , brand, amount, frequency

Medical History for Exam

Please answer yes, no or short descrption for each

History - Any changes in appetite, water consumption or urination

Any Coughing or Sneezing - (Yes, no, both)

Any Voming or Diarrhea (yes, no, both)

History - Itchy- Skin, ears? (what location)

History - Limping? (which leg/legs)

Any Lumps/Bumps- Location(s)

Any Previous History of Vaccine Reactions?

Is your pet mostly indoors or outdoors

Please explain any of previous questions or any other concerns you would like addressed during exam

Any other services we can help you with today (heartworm, Flea/tick, foods, medication refills)