Comprehensive Pet History

Comprehensive Pet History

Douds Veterinary Hospital
Owner's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Pet's Name
Do you have an upcoming appointment with us?
If so, please tell us the date and time
If this is your first visit, is this your first pet?

NoYesNot my first visit
Are you aware that pet insurance is available?

NoNo, tell me moreYes
Has your pet been microchipped?

NoNo, but I am interestedYes
Are you planning on boarding or grooming your pet within the next 6 months?

NoYes
Reason for your pet's visit?
Annual exam & vaccines, or another reason
Has your pet been seen for the same condition recently?
No, or if yes, when?
Are your pet's vaccinations up to date?

NoYesDon't know
Is your pet spayed or neutered?

NoYesDon't know
Has your pet's stool been checked for parasites within the last 6 months?

NoYesDon't know
Have you seen any worms in your pet's stool?
No, or if yes, please describe.
Is your pet on heartworm prevention?

NoYes, year roundYes, part of the year
What heartworm product(s) do you use?
What day of the month do you give the heartworm prevention?
Is your pet on flea prevention?

NoYes, year roundYes, part of the year
What flea prevention product(s) do you use?
Has your pet had any illness or injury within the last 30 days?
No, or if yes, please describe
Is your pet currently on any medications?
No, or if yes, please list
Any known allergies to drugs/medications?
No, or if yes, please list
What dental care do you provide at home and how often?
What do you feed your pet?
List brand and amount
What treats do you feed your pet?
What table scraps do you feed your pet?
Does your pet have any food intolerances?
No, or if yes, please describe
Did your pet eat this morning?

NoYes
Appetite:

DecreasedNormalIncreased
Weight:

LossStableGain
Water consumption:

DecreasedNormalIncreased
Bowel movements:

ConstipatedNormalDiarrhea
Urinations: (Check all that apply)

DecreasedNormalIncreased amountIncreased frequencyStrainingIncontinence (loss of housetraining)
Vomiting:

NoYes
Coughing:

NoYes
Excessive panting:

NoYes
Difficulty breathing:

NoYes
Sneezing:

NoYes
Gagging:

NoYes
Listlessness/lethargy:

NoYes
Weakness:

NoYes
Shaking head:

NoYes
Scratching?
No, or if yes, describe location
Significant hair loss:

NoPatchy lossGeneralized lossExcessive shedding
Scooting:

NoYes
Bad breath:

NoYes
Lumps or bumps:
No, or if yes, describe location
Unusual discharge:
No, or if yes, describe location
Lameness:
No, of if yes, which leg? RF, RR, LF, LR
Difficulty rising:

NoYes
Difficulty climbing stairs:

NoYes
Stiffness:

NoYes
Behavioral changes:
No, or if yes, please describe
Is your pet having any other problems or issues that you would like to to discuss with the doctor at the appointment?
Thank you for providing this information! Although we may not be able to address all of your pet's health concerns in this one appointment, we value this information as a tool to help keep your pet healthy and happy in future visits!
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