Medical History
Your pet's full name
*
Last name
Pet's Name
Phone Number to use during appointment
*
-
Area Code
Phone Number
What is your pet here for today
Check if you pet is experiencing any of these symptoms:
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Vomiting
Diarrhea
Sneezing
Coughing
Drinking more water than usual
Urinating more than usual
None of the above
Change in weight, loss or gain
Other
How frequently has the vomiting been taking place?
When did the vomiting start?
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Month
-
Day
Year
Date
How frequent is the sneezing?
When did the sneezing start?
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Month
-
Day
Year
Date
How frequent is the diarrhea?
How has the diarrhea been progressing?
Has been getting better
Has been getting worse
Has stayed the same
Other
When did the diarrhea start?
-
Month
-
Day
Year
Date
How frequently is your pet coughing?
When did the coughing start?
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Month
-
Day
Year
Date
Is your pet drinking more or less than normal?
More than normal
Less than normal
Other
Approximately when did this drinking change start?
-
Month
-
Day
Year
Date
What change have you noted in you pet's urination?
More frequent, normal amount
More frequent, small amount
Less frequent, normal amount
Less frequent, small amount
Other
Approximately when did this change in urination start?
-
Month
-
Day
Year
Date
Is your pet gaining or losing weight?
Gaining fairly quickly
Gaining gradually
Losing fairly quickly
Losing gradually
Other
Approximately when did you first notice this weight change?
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Month
-
Day
Year
Date
Is there any significant past medical history that Alpine needs to know about?
Is your pet currently taking any medication or supplements?
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Yes
No
Please list any medication or supplement your pet is taking
Rows
Name of the medication
Dosage (the strength of the medication and how much you give)
How often do you administer this medication?
First medication
Second medication
Third medication
Fourth medication
Fifth medication
Sixth medication
Is your pet current on heart worm prevention?
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Yes
No
What is the name of the heart worm preventative you use?
Is your pet currently on a flea and tick preventative?
Yes
No
What is the name of the flea/tick preventative you use?
Do you need a refill of these preventatives?
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I would like to get heart worm preventative from Alpine
I would like to get flea/tick preventative from Alpine
I need both types of preventative
I do not need a refill at this time
Other
What diet is your pet currently eating?
A brand name or similar would make sense.
Is that a grain free diet?
Yes
No
Not sure
Alpine Veterinary Hospital may charge an exam fee for appointments cancelled with less then 24 hours notice over a business day. More details are in your appointment confirmation email and at the end of this form.
*
I understand
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Help us understand your pet's wellbeing
Does your pet show any reluctance getting into:
their carrier
your car
both
neither
Which description best matches your pet's behavior while traveling
eager/excited
subdued
more quiet than usual
more vocal than usual
Does your pet exhibit any of these behaviors while travelling?
pant
tremble
pace
hide
drool
vomit
poop
pee
Are there any situations that your pet has tried to avoid or seemed to dislike in the past?
entering the hospital
interacting with unfamiliar people or pets
being weighed
entering the exam room
going onto the exam table
having their temperature taken
ear exam/cleaning
nail trim
Has your pet ever tried a supplement or medication to help manage fear or anxiety? If so, do you recall what was used and what the results were?
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