Patient History Report

Patient History Report

Hickory Grove Animal Hospital
Patient Name
Owner Name

First NameLast Name
Cell Phone # (where you can be reached now)
Please enter a valid phone number.
Reason for visit today?
Symptoms?
Appetite ( decrease / Increase / not eating )....How long?
Behavioral Changes?
Cough / Sneeze/ Nasal Discharge Describe....How long?
Vomiting / Diarrhea.... How long...… Worsening / Improving / Resolved?
Drinking More /Urinating More / Urinary Accidents?
Shaking Head / Scratching Ears?
Lumps / Masses... New Mass / Current Mass Enlarging..... Present for how long.... location(s)?
Lameness / Limp Which leg..... How Long / Worsening/Improving?
Pain / Crying?
Other
Indoor Pet / Outdoor Pet / Both?
Previous treatment from another vet: Name and location of previous vet?
Currently On / Off Heartworm Prevention. How long off? Type of Prevention?
Need Refill? If so, quantity and name of product?
Currently On / Off Flea and Tick Control. Type of Flea control.
Need Refill? If so, quantity and name of product?
Diet Name / Can/Dry / Recent changes?
If so, when and from what diet?
When was your pet’s last meal? What did he/she eat?
What medications (if any) has your pet received in the last 24 hours?

Please provide all information
Name of Medication / Amount given / What time?
Name of Medication / Amount given / What time?
Name of Medication / Amount given / What time?
What other medications (if any) is your pet currently receiving

Please provide all information
Name of Medication / Amount given / What time?
Name of Medication / Amount given / What time?
Name of Medication / Amount given / What time?
Is your pet sensitive or allergic to any medications or food

YesNo
If so, what products?
If we recommend a special diet, would you prefer can or dry or both?
OTHER PERTINENT INFORMATION RELATED TO YOUR PET’S EVALUATION?
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED
We will examine your pet and call you for recommended treatment options and for additional questions. Please be available for the phone call at the number you provided us at the time of your appointment.
This report prepared by (name)
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Patient History Report

What medications (if any) has your pet received in the last 24 hours?

What other medications (if any) is your pet currently receiving

We will examine your pet and call you for recommended treatment options and for additional questions. Please be available for the phone call at the number you provided us at the time of your appointment.