Latham Animal Hospital Patient history form

Patient Exam History Form

Existing clients and patients
Your name

First NameLast Name
Pet's name
Phone Number

Area CodePhone Number
Email
example@example.com
COVID-19 Health Survey:

Please answer these questions honestly so we can prepare proper levels of PPE to keep our team safe. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:

Rows	YES	NO
Do you have a fever or above normal temperature?
Have you experienced shortness of breathe or had trouble breathing?
Do you have a dry cough?
Have you recently lost or had a reduction in your sense of smell?
Are you under quarantine for any COVID 19 reasons?
Have you traveled outside the United States by air or cruise ship in the past 14 days?

Explain any YES answers in the box below:
Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
Let's start with their mouth:
Do you have a concern for your pet's mouth or teeth?
What are your concerns (check all that apply)?

Other
Has your pet experienced this before?
How long has this been going on?
Additional notes:
And their eyes:
Do you have concern about your pet's eyes?
I have concerns about (check all that apply):

Other
Has your pet experienced this before?
Which eye?
How long has this been going on?
How much time outside?
Any exposure to chemicals/irritants:
Have you observed:
Ears:
Do you have a concern for ears?
My pet's ears (check all that apply):
Which ear?
Has your pet experienced this before?
How long has this been going on with the ears and has pet had previous issues?
Is there:
Have you observed:
Additional notes-are you using any cleaners or medications at this time?:
Respiratory:
Do you have concerns about your pet's breathing?
My pet (check all that apply)

Other
Has your pet experienced this before?
How long has this been going on?
How often is your pet displaying problems (check all that apply)?
Have you seen changes in activity level?
Environment:
Additional notes:
Skin and Body:
Do you have concerns about your pet's skin?
My pet is:
My pet's coat and body (check all that apply)

Other
Has your pet experienced this before?
How long has this been going on?
Environmental changes:
What medications or treatments have you used?
Mobility and movement:
Do you have concerns about your pet's walking and play?
My pet (check all that apply)

Other
Has your pet experienced this before?
What is most affected?

Other
How long has this been going on?
Additional information:
GI system/weight/appetite
Do you have concerns about your pet's eating and elimination behavior?
My pet (check all that apply)

Other
For primary nutrition, my pet eats (check all that apply):
My pet (check all that apply)

Other
Has your pet experienced this before?
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
Additional information and concerns:
Behavior:
Do you have concerns about your pet's behavior?
My pet (check all that apply)
Has your pet experienced this before?
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
Additional information and concerns:
My primary concern today is:
Are there any other questions that you would like us to address at your visit?
Thank you so much for completing this survey. We appreciate your deep knowledge of your pet, and this helps us partner more effectively with you to develop the best plan to address your concerns and meet your pet's and your family's needs.
Date

MonthDayYear
Date
Should be Empty:

Patient Exam History Form

COVID-19 Health Survey:

Let's start with their mouth:

And their eyes:

Ears:

Respiratory:

Skin and Body:

Mobility and movement:

GI system/weight/appetite

Behavior: