Patient History Questionnaire

Please call or text us at 760-228-1474 when you arrive for your appointment. After a technician retrieves your pet from your car, you're welcome to join us in the building. Only 1 person is allowed in the building per appointment. Please arrange child care if you wish to accompany your pet into the clinic. Finally, MASKS ARE MANDATORY, even if you have been vaccinated.

Your name: *

First Name Last Name

Your pet's name: *

I will be reachable at this phone number: *

Area Code Phone Number

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

Yes No

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

Yes No

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

Yes No

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

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 appetite Coughing Sneezing Vomiting Diarrhea Change in thirst Change in urination NONE

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 dogs Leptospirosis vaccine for dogs Bordetella vaccine for dogs Rattlesnake vaccine for dogs Lyme vaccine for dogs FVRCP combination vaccine for cats Feline Leukemia vaccine for cats

Would you like any of the following performed on your pet today? Check all desired.

Toenail trim Anal gland expression Heartworm test Wellness blood test (CBC/chemistry to check organ function and blood cell counts) FIV/FeLV test for cats Gastrointestinal 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.

If I miss this appointment without calling Companion Animal Clinic to inform them ahead of time, I understand that I will be charged a $25.00 deposit if I want to schedule another appointment. That $25.00 will be deducted from my invoice balance on the day of the new appointment. If I miss the new appointment without letting CAC know ahead of time, the deposit is nonrefundable.

Date *

Date

Signature *

Clear

Patient History Questionnaire

*This is for appointments that have already been scheduled*

This is for appointments that have already been scheduled