Patient History Questionnaire

Patient History Questionnaire

Companion Animal Clinic
*This is for appointments that have already been scheduled*
If you miss or move this appointment without calling Companion Animal Clinic more than 24 hours in advance, your account will be charged a $50.00 no-show fee.
Your name:*

First Name Last Name
Your pet's name:*
I will be reachable at this phone number:*

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Has anyone in your household experienced any COVID-like symptoms (fever, coughing, shortness of breath, etc.) in the last 2 weeks?*

YesNo
Has anyone in your household tested positive for COVID-19 in the last 2 weeks?*

YesNo
Has anyone in your household been exposed to anyone with a positive COVID-19 test result in the last 2 weeks?*

YesNo
If you answered "Yes" to any of the COVID-19 screening questions above, we will still see your pet, but we will take extra precautions. You are also welcome to have a friend bring your pet in for you and we will call you if we have any questions.
Would you like to update your pet's photo for their chart? If so, please click "Browse Files" and select their picture.

Browse Files

Cancelof
What type of exam does your pet need today?*

Wellness examination (no health issues, concerns, or injuries)Illness, injury, or any other medical concerns
For illnesses, injuries, or other medical issues, please describe the concerns you have.
For illnesses, injuries, or other concerns, when did the issue start? Has the issue gotten better, worse, or stayed the same since it began?
If your pet is on any medication, supplements, over-the-counter products or preventatives, please list them along with how much and how often they are given.
What does your pet's diet consist of? Please list the brand, amount, frequency, treats, and table food.*
Has your pet experienced any of the following? Please check all that apply.*

Change in appetiteCoughingSneezingVomitingDiarrheaChange in thirstChange in urinationNONE
What is your pet's travel history outside of the Morongo Basin?*
What percentage of the time is your pet outdoors?*
Do you have any additional concerns you'd like to discuss with the doctor?
For wellness exams ONLY, would you like any of the following vaccines given to your pet today? Check all desired.

Rabies vaccine (Required by law for dogs, recommended for outdoor cats)DHP (parvo) combination vaccine for dogsLeptospirosis vaccine for dogsBordetella vaccine for dogsRattlesnake vaccine for dogsLyme vaccine for dogsFVRCP combination vaccine for catsFeline Leukemia vaccine for cats
Would you like any of the following performed on your pet today? Check all desired.

Toenail trimAnal gland expressionHeartworm testWellness blood test (CBC/chemistry to check organ function and blood cell counts)FIV/FeLV test for catsGastrointestinal parasite screen (stool sample; if we can't obtain a sample here, a container will be sent home with you)Please call me to discuss vaccine and lab test recommendations and/or costs
By signing this form, I agree to have the services that I checked performed on my pet. I understand that any vaccine has the potential to cause an allergic reaction ranging from mild to severe and that vaccines may cause lethargy, soreness and mild fever. Reactions are more common in dogs under 20 pounds receiving more than one vaccine at a time.
Date*

MonthDay Year
Date
Signature*

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Patient History Questionnaire

*This is for appointments that have already been scheduled*

This is for appointments that have already been scheduled