New Patient Intake Form
Owner's Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary phone number
Please enter a valid phone number.
Secondary phone number
Please enter a valid phone number.
How did you hear about us?
Facebook
Website
Other Veterinarian
Other
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Patient Information
Patient Name
Date of Birth
-
Month
-
Day
Year
Date
Species
Dog
Cat
Other
Breed
Coat Color
Male or female?
Male
Female
Reproductive Status
Spayed
Neutered
Intact
Other
Patient's weight
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Problem History
Please list the main issues you would like to focus on:
How long have the issues been present?
Initial cause, if known:
How has this been treated so far?
What has been successful?
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General Health History
Does your animal have any of the following?
Adverse vaccine reaction
Allergies
Anxiety
Autoimmune dysfunction
Cancer
Dental disease
Diabetes
Frequent antibiotic use
Seizures
Thyroid problems
Are there any problems with diet, water intake, or weight?
Yes
No
What are the specific concerns with diet, water intake, or weight?
Weight gain
Weight loss
Excessive water intake
Excessive appetite
Low appetite
Other
What kind of food is your pet eating?
Are there concerns with eyes, ears, nose, or throat?
Yes
No
What are the specific concerns with eyes, ears, nose, or throat?
Red eyes
Itchy eyes
Difficulty seeing
Difficulty hearing
Frequent ear infections
Nasal discharge
Other
Are there respiratory problems?
Yes
No
What are the respiratory problems?
Allergies
Coughing
Sneezing
Difficulty breathing
Other
Are there heart problems?
Yes
No
What are the heart problems?
Heart murmur
Passing out
Blood pressure issues
Other
Are there gastrointestinal issues?
Yes
No
What are the gastrointestinal issues?
Diarrhea
Constipation
Loose stool
Blood in stool
Mucus in stool
Belching
Gas
Excessive salivation
Food sensitivities or food allergies
Other
Are there musculoskeletal issues?
Yes
No
What are the musculoskeletal issues?
Tremors
Weakness
Limping
Trouble getting up
Stiffness
Other
Are there issues with skin or hair?
Yes
No
What are the issues with skin or hair?
Licking
Scratching
Rash
Dandruff
Hairloss
Other
Are there psychological issues, like anxiety or high stress levels?
Yes
No
What are the psychological issues?
Agression
Anxiety
High stress
Irritability
Other
Are the issues with urination?
Yes
No
What are the issues with urination?
Frequent urination
Large volume of urine
Blood in urine
Bedwetting
Other
Please list any other issues or concerns not covered:
Please list all medications:
Please list all supplements:
Please list all surgeries:
Please give the details of any hospitalizations:
Who is your regular veterinarian or veterinarian's office?
Do you give permission to request records from your regular veterinarian?
Yes
No
Submit
Should be Empty: