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:*

	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: *

Clear
Let's start with their mouth:
Do you have a concern for your pet's mouth or teeth?

YesNo
What are your concerns (check all that apply)?

Odor coming from mouthGums are red and irritatedTartar and/or discoloration on teethLumps and bumps around mouthConcerns about loose or broken teethHaving trouble chewing or drinkingOther
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Additional notes:
And their eyes:
Do you have concern about your pet's eyes?

YesNo
I have concerns about (check all that apply):

Are red and irritatedHave a gunky dischargeAre "weepy"Are cloudy.Vision-my pet does not seem to see well.Frequently scratching or rubbing themOther
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Which eye?

RightLeftBoth
How long has this been going on?
How much time outside?
Any exposure to chemicals/irritants:
Have you observed:

SneezingCoughingNasal DischargeChange in appetiteVomiting or diarrheaItching or scratching on other parts of body
Ears:
Do you have a concern for ears?

YesNo
My pet's ears (check all that apply):

have some gunk and debris once in awhile.always seem to have some debris.sometimes have a yellow or brown discharge.seem red or swollen on the inside.seem swollen or irritated on the outside.seem itchy. S/he scratches them frequently.are of concern. My dog does not seem to hearing as well as s/he used to.
Which ear?

RightLeftBoth
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
How long has this been going on with the ears and has pet had previous issues?
Is there:

Head shakingHead tiltOdor from the ear(s)
Have you observed:

SneezingCoughingNasal DischargeChange in appetiteVomiting or diarrheaItching or scratching on other parts of bodyChanges in dietChanges in swimming or bathing behavior
Additional notes-are you using any cleaners or medications at this time?:
Respiratory:
Do you have concerns about your pet's breathing?

YesNo
My pet (check all that apply)

seems to cough, sneeze, or gag more that s/he used to.seems to pant more.has changed his or her vocalizations.seems to get out of breath easily.seems to be more anxious, and I feel like his or her heart is beating faster at times.has intense coughing or gagginghas intense panting at timesOther
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
How often is your pet displaying problems (check all that apply)?

Cough or sneezes once or twice dailyCoughs or sneezes multiple times dailyMore frequent in the dayMore frequent at nightWorsens after exercise or movementFrequent pantingIncreased abdominal effort with breathingFainting episodes
Have you seen changes in activity level?

Less active than normalActivity level is the sameMore active than normalAppears lethargicAppears agitated
Environment:

My dog goes to a groomer or doggie day careMy dog visits other households with pets or dog parksI foster pets and/or volunteer at a rescue or shelterThere are other pets in the household with respiratory symptoms.We have COVID-19 exposure in our household.
Additional notes:
Skin and Body:
Do you have concerns about your pet's skin?

YesNo
My pet is:

scratchinglickingchewing/biting
My pet's coat and body (check all that apply)

is dull and not as soft as it used to be.is dry and my pet scratches frequently.seems to have an odor, and I see some crusty skin.has some hair loss.has open sores that do not heal.has some lumps and bumps.has patches of hardened or thickened skin.Has hot spotsHas a rashOther
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
How long has this been going on?
Environmental changes:

My pet goes outside.My pet has been exposed to potential chemical irritants.There are other pets in the household with skin symptoms.My pet has had a change in diet.
What medications or treatments have you used?

regular bathsmedicated bathsOTC sprays/ointmentsOTC or natural flea/tick productsPrescription flea/tick productsPrescription oral medicationsFoods or supplements such as fish oil
Mobility and movement:
Do you have concerns about your pet's walking and play?

YesNo
My pet (check all that apply)

seems awkward sometimes and limps once in awhile.is playing less than s/he used to, and having trouble moving.is slowing down and does not seem as interested in play.is stiff and has difficulty with stairs and climbing.seems to be painful sometimes when moving around.has an acute injury and is not walking on/toe touching one limbOther
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
What is most affected?

Right front legLeft front legBoth front legsRight rear legLeft rear legBoth rear legsHips and entire back areaOverall mobility concernsOther
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?

YesNo
My pet (check all that apply)

Is gaining weight eating the same amount of food.has gained weight and is eating more.has gained weight but s/he is actually eating less.has lost weight but is still eating like s/he used to.has lost weight and is eating less.seems to be hungry all the time.seems to be thirsty all the time.is drinking more water than s/he used to.seems to have trouble eating his/her normal food.Does not seem to be that interested in food/refusingOther
For primary nutrition, my pet eats (check all that apply):

a homemade diet.a raw food diet.a high quality commercial dry food.a high quality commercial wet food.a prescription diet.a commercial name brand dry food.a commercial name brand wet food.a store brand dry food.a store brand wet food.only people food.
My pet (check all that apply)

is having trouble controlling his/her bladderis making messes in the houseseems to be urinating more frequently.seems to be defecating more frequently.has strong smelling urine.has unusually strong smelling stools.has frequent loose stools or diahrrea.seems to get constipated.seems to get nausea frequently.seems to vomit frequently.seems to have a sensitive stomach.frequently gets into stuff s/he should not eat.Other
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
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?

YesNo
My pet (check all that apply)

continues to struggle with behavioral problems (please let us know what these are)is showing increased anxietyis showing increased aggressionsometimes seems confusedis not as responsive to us as s/he used to beis lethargic and sometimes acts depressed
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
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.
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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: