Patient History Form for Appointments, Boarding and Drop Offs

Patient History Form

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name*

First NameLast Name
Your Name*

First NameLast Name
It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your phone listed below available and be free to talk.
Where can we call you at while your pet is here?*
Date of your pet's appointment*
Reason for your pet's visit today?*
Are we seeing a New Pet? If yes, please tell us about your new pet: Age, Breed, Sex, Color and if Spayed/Neutered
This issue began on:
Date
This issue is:
Has your pet had any:

CoughingSneezingVomitingDiarrhea
Color
Texture
Frequency
Consistancy
Duration
Blood present?

YesNo
Is the cough productive?

YesNoI'm not sureOther
Is there mucous present?

YesNoI'm not sureOther
Color
Has your pet had any:

New lumps or bumpsBehavior changesChanges in mobility
Please Describe Changes
Location of Lumps/Bumps
When Did You Notice Them?
Any Discharge or Odor from Bumps?
My pet's appetite is:
If increased or decreased, please provide more information:
My pet's thirst level is:
If increased or decreased, please provide more information:
My pet's activity level is:
If increased or decreased, please provide more information:
My pet's urination is:
Color
Amount
Frequency
Duration of Abnormal Urination
Does your pet have any allergies or has had a reaction to a vaccine or medication?
My pet eats

Wet food onlyDry food onlyWet and Dry MixturePeople FoodRaw DietHome Cooked DietOther
Brand of Pet Food
If prescription diet, what formulation?
How Often Is Your Pet Fed?
How Much Is Your Pet Fed?
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)
Has your pet's diet changed in the last 6 months?

YesNoI am not sure
Is it possible for your pet to have:

Eaten garbageIngested toxins (rat bait, ant bait, other known toxic substances)Ingested MushroomsIngested MarijuanaEaten toys (part of toys missing, chewed up etc.)Eaten grain free diet for any period of timeIngested human or animal medications not intended for them or at higher doses than intended?NONE OF THE ABOVE ARE POSSIBLE
Please tell us more:
Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:*
When Was Your Pet's Last Dose of Heartworm Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Heartworm Preventative Do You Use?
Name of medication - put unknown if not sure
When Was Your Pet's Last Dose of Flea/Tick Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure
Is Your Pet:

Indoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightOther
Are There Other Pet's In The Home

YesNoFarm Animals
Please tell us about the other pet's in your home
Does Your Pet:

Visit the dog parkGet Groomed RegularlyCompete in Dog/Cat ShowsAttend Obedience TrainingAttend Agility/Dock Diving/Search and Rescue programs etc.BoardAttend Doggie DaycareTravel with you (inside North Carolina)Travel with you (outside North Carolina)
Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure
My pet's vaccines were administered last by:

At Cape Fear Animal HospitalI Am Not Sure WhereOther
Does Your Pet Have A Microchip?

YesNoI Am Not Sure
Has Your Pet Bitten Anyone In the Last 10 Days?

YesNoI Am Not Sure
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Please upload if available.
Cancelof
Is There Anything Else You Would Like To Discuss Today?
Do you consent to following diagnostics if recommended following the examination?
Appointment Procedures
I understand that my pet is required to have certain up-to-date services while at Cape Fear Animal Hospital for the day or overnight and those vaccines will be given at my expense if my pet is found well enough to be vaccinated. All pets are requried to have been seen by one of Cape Fear Animal Hospital's Veterinarians at minimum one time per year. Dogs are requried to have a negative fecal exam within 6 months of overnight stays. (Dogs-Distemper/Parvo, Kennel Cough, Flu and Rabies. Cats-Rabies and Distemper)*
Initial
I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.*
Initial
Email
example@example.com
Signature*

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Should be Empty:

Patient History Form

Appointment Procedures