PET HISTORY FORM

PET INFORMATION & HISTORY FORM

To help protect our clients and employees from exposure to the COVID-19 virus, we are utilizing curbside and drop-off appointments at this time. Our hospital asks that you fill out this form in order to better facilitate the examination of your pet(s) and clarify your concerns so they may be addressed appropriately. We will speak with you directly to verify if there are any changes or additions to this before we examine your pet and we will consult with you again after the exam if any problems are noted.

Thank you for your patience as we strive to provide your pet with necessary care while preventing the spread of COVID-19 in our community.

Client Name First Name Last Name

Are you the pet owner? If not, please note relationship and your name below.

YesNo

First Name Last Name Relationship to owner

Have you or the person bringing this pet to us been ill (with cough, fever, or shortness of breath) or diagnosed with or exposed to COVID-19 within the last 14 days? If you answer yes to this question, please have another responsible party bring your pet to the appointment or reschedule for another time.

YesNo

Are you a new client to our clinic?

YesNo

Pet's Name Name

If you are not a new client, is this a new pet for you? Please complete the specific questions below if this is a new pet (otherwise skip to reason for coming today section)

YesNo

Species

DogCatRabbitOther

If species is OTHER, please enter hereblanks

Gender/Sex

Intact MaleNeutered MaleIntact FemaleSpayed female

Age or Date of Birth (if known)

Breed (if known/best guess):

Color:

Does this pet have any known allergies to vaccines or medications?

YesNo

If you answered yes, please describe

My pet is presenting today for (check all that apply)

If other, please indicate briefly

Pet food brand

Type of food

Wet/CannedDry/KibbleBoth

Is this a new food for them?

YesNo

Is this pet currently taking or on

Heartworm PreventiveFlea/Tick ControlBothNeither

Brand of Heartworm Preventive & date last administered blanks
Brand of Flea/Tick Control & date last administered blank

My pet takes the following medications and supplements (please list as much detail as possible and when they were last administered):

Current Pet Health: My pet seems healthy & there are no specific concerns today. If your pet has been unwell or you have specific concerns about their recent health, please answer the questions directly below. We will inquire further if more information is needed about your pet's specific symptoms.

YesNo

If you answered yes, you may skip to the last section of this document.

Is this pet eating normally?

YesNo, less than usualNo, more than usualNo, not eating at all (or barely)

Is this pet vomiting (recently)?

YesNo

Frequency of vomiting is:

IncreasingDecreasingNot changed much

Appearance of vomit and how often:

This pet last vomited:

Are this pet's stools normal or abnormal?

NormalHard/DrySoftWatery diarrhea

What color are the stools? Do they contain visible blood?

Do you believe your pet has...

Lost WeightGained WeightProbably not changed

Has your pet recently exhibited...

Lameness or LimpingStiffnessPain or TendernessSeemed Sore anywhere

If any of the above, for how long?

I suspect one or more of the following are bothering my pet

This started approximately when?

Since it started, has it...

ImprovedWorsenedBeen about the same

If your pet has recently traveled, where did they travel?

Has your pet recently been boarded, groomed, attended a dog show, dog classes, athletic competitions?

YesNoOther

Please note any medication refill requests below (allow 6 hours for refills; longer for special orders):

Any other questions or concerns regarding today's visit?

Please list your previous hospital so we can get medical records

I am the owner/agent for described animal and authorize, and request an exam for this pet. I understand that sedation and/or pain medication will be provided if deemed necessary. I understand the doctor or nurse will contact me after my pet has been evaluated to discuss the recommended diagnostics and/or treatment and will provide an initial estimate of charges if desired.

I can be reached at the following phone number:

Form completed by:

Signature

Date completed:

Date

Thank you again for providing this information as it will facilitate our understanding of your pet’s concerns and allow us to provide better care and service.