Parkview Patient History Form

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Summary of Patient's Health for Exam

Summary of Patient's Health for Exam

This form is specifically for patients with existing appointments at Parkview Animal Hospital. Filling out this form WILL NOT create an appointment at Parkview Animal Hospital. In an effort to keep our clients and staff as healthy as possible, we are limiting permission to enter the facility directly. We request that you fill out this exam summary electronically prior to your appointment. Thank you!

Language

English (US)

1
Your full name* This field is required.
First Name
Last Name
2
Cell phone number to reach you while your pet is in the building.* This field is required.The Veterinarian and support staff will use this number to communicate with you through the appointment. Please have your cell phone listed above available and be free to talk.
Area Code
Phone Number
3
Have you, your pet, or someone in your home exhibited ANY of the following symptoms in the last 14 days: cough, fever, shortness of breath, difficulty breathing?* This field is required.
Yes
No
4
Have you or your pet traveled outside of New Jersey in the last 14 days?
Yes
No
5
Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?
Yes
No
6
Patient's name* This field is required.
7
Appointment Date/Time
Date
Year
Month
Day
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
8
Patient's Species* This field is required.
Canine
Feline
9
Patient's Sex* This field is required.
Male/Neutered
Female/Spayed
Male/Intact
Female/Intact
10
Please describe the primary reason for your pet's visit today and any concerns you have* This field is required.Please be as detailed as possible.
11
Is your pet:
Indoor Only
Mostly Indoor but Rarely to Occasionally Spends Time Outdoors
Indoor/Outdoor
Outdoor Only
Outdoor During Day/Inside At Night
12
Does your pet:
Visit the dog park
Get groomed regularly
Compete in dog/cat shows
Attend obedience training
Attend agility/dock diving/search and rescue programs etc.
Board
Attend doggie daycare
Travel with you (inside NJ)
Travel with you (outside NJ)
None of the above
13
Are there other pets in the home
Yes
No
14
Please tell us about the other pet's in your home
15
What kind of heartworm preventative do you use?
Name of medication - put unknown if not sure or N/A if not on a preventative
16
When was your pet's last dose of heartworm preventative?
Date Given (Please type N/A if not on a preventative)
17
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure or N/A if not on a preventative
18
When Was Your Pet's Last Dose of Flea/Tick Preventative?
Date Given (Please type N/A if not on a preventative)
19
Is the patient on any other medications?* This field is required.Please list any prescription medications, supplements, OTC medications, or topical treatments (shampoos, creams, ointments, etc.) your pet has received in the past 3 months AND when they were last given.
20
Do you need refills on your pet's heartworm preventative, flea and tick prevention, or any other medications? If so, which ones?* This field is required.Please type N/A if you don't have any medications
21
How is the patient's energy level* This field is required.
Normal
Increased
Decreased
22
How is the patient's appetite?* This field is required.
Normal
Increased
Decreased
23
What type/brand of food does the patient eat?* This field is required.
24
How is the patient's drinking/water intake?* This field is required.
Normal
Increased
Decreased
25
Is the patient coughing?* This field is required.
Yes
No
I'm not sure
26
Is the patient sneezing?* This field is required.
Yes
No
I'm not sure
27
Is the patient vomiting?* This field is required.
Yes
No
I'm not sure
28
Does the patient have diarrhea?* This field is required.
Yes
No
I'm not sure
29
How is the patient's urination?Select all that apply.
Normal
Increased
Decreased
Blood Present
Dark
Cloudy
Straining to urinate
Strong/foul odor
30
Has your pet had any physical or behavioral changes?Select all that apply
New lumps or bumps
Behavior changes
Changes in mobility
Other
None
31
Please Describe Changes
32
Please describe the lumps/bumpsLocation? Any discharge or odor? How long have they been there? Have they gotten smaller or larger?
*We recommend sending photos ahead of time or marking lumps for exam
33
Does your pet have known health concerns and/or chronic disease or conditions?Please email records to info@pvahnj.com if applicable.
If yes, please tell us more. If no, please note N/A
34
Would you like your pet to have a nail trim at his or her appointment? There is an additional charge for this service.
YESNO
35
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
36
Has Your Pet Bitten Anyone In the Last 14 Days?
Yes
No
I Am Not Sure
37
Are there pictures or video that would help us with our exam today?
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Please upload if available.
Cancelof
38
I understand I should text 973-473-4993 to check in when I arrive. I also understand that I should remain in my vehicle at all times while on Parkview Animal Hospital grounds except for when a Parkview team member instructs me to go to the entrance.* This field is required.This is for your safety and the safety of our clients and patients.
Initial
39
I understand that access to the Parkview Animal Hospital building is limited to employees only at this time. * This field is required.We are unable to offer restroom access.
Initial
40
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.* This field is required.
Initial
41
In order to keep our staff and clients safe, we kindly ask that you call the office to reschedule your appointment.
42
Signature
43
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