Parkview Patient History Form

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. (The number of the person who is going to be here with the pet.)* 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

Has your address, phone number or email address changed since you were last here?

YESNO

4

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

5

Have you or your pet traveled outside of New Jersey in the last 14 days?

Yes

No

6

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

7

Patient's name* This field is required.

8

Appointment Date/Time

Date

Hour

Minutes

9

Patient's Species* This field is required.

Canine

Feline

10

Patient's Sex* This field is required.

Male/Neutered

Female/Spayed

Male/Intact

Female/Intact

11

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.

14

Are there other pets in the home

Yes

No

15

Please tell us about the other pet's in your home

16

What kind of heartworm preventative do you use?

Name of medication - put unknown if not sure or N/A if not on a preventative

17

When was your pet's last dose of heartworm preventative?

Date Given (Please type N/A if not on a preventative)

18

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

19

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

20

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.

21

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

22

How is the patient's energy level* This field is required.

Normal

Increased

Decreased

23

How is the patient's appetite?* This field is required.

Normal

Increased

Decreased

24

What type/brand of food does the patient eat?* This field is required.

25

How is the patient's drinking/water intake?* This field is required.

Normal

Increased

Decreased

26

Is the patient coughing?* This field is required.

Yes

No

I'm not sure

27

Is the patient sneezing?* This field is required.

Yes

No

I'm not sure

28

Is the patient vomiting?* This field is required.

Yes

No

I'm not sure

29

Does the patient have diarrhea?* This field is required.

Yes

No

I'm not sure

31

Has your pet had any physical or behavioral changes?Select all that apply

New lumps or bumps

Behavior changes

Changes in mobility

Other

None

32

Please Describe Changes

33

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

34

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

35

Would you like your pet to have a nail trim at his or her appointment? There is an additional charge for this service.

YESNO

36

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

37

Has Your Pet Bitten Anyone In the Last 14 Days?

Yes

No

I Am Not Sure

38

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.

39

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

40

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

41

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

42

In order to keep our staff and clients safe, we kindly ask that you call the office to reschedule your appointment.

43

Signature

44

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