Patient History
Today's date
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-
Month
-
Day
Year
Date
Arrival time
Note am or pm
Pet Name
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First and last
Why are you bringing your pet in for evaluation today?
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When did symptoms first appear?
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How have symptoms changed since first noticed?
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What treatments have been provided for this concern?
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Includes at home remedies and treatments provided by your family veterinarian
Has your pet experienced any recent vomiting?
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Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent diarrhea?
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Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent loss of appetite?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent excessive consumption of water?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent excessive urination?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent straining to urinate?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent straining to defecate?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent sneezing?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent coughing?
*
Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
Has your pet experienced any recent lethargy or change in energy level?
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Please Select
Yes
No
If yes, please explain
If you answered yes, please describe.
What prescription medications does your pet receive? Name drug, strength of drug (mg for example), and frequency. If none, enter none.
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What over the counter medications or supplements does your pet receive?
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Does your pet have any known drug allergies or sensitivities? Please list any known or perceived drug adverse reactions:
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List any chronic illnesses or prior conditions:
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Please list the date of your pet’s most recent exam by a veterinarian?
What vaccinations has your pet received within the previous 3 years, include date or estimated date?
What date was the last rabies vaccination provided?
What type of pet food does your pet receive? (type, amount, and frequency)
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List any food allergies, sensitivities, or dietary restrictions:
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What snacks, treats or table scraps does your pet receive?
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Please select which best describes your pet’s lifestyle:
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Please Select
Indoors only
Indoor/outdoor
Outdoor only
Please list other pets in your household, include type:
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Are any of the other pets sick?
*
Please Select
Yes
No
N/A
If yes to other pets being sick, please describe.
Any exposure to lakes, streams, ponds, beach, dog park or day care within last 14 days?
*
Please Select
Yes
No
Has your pet ever traveled outside the Bay Area?
*
Please Select
Yes
No
If yes to above, please describe where.
Has your pet ever received a blood transfusion?
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Please Select
Yes
No
I do not know
Has your cat been tested for FeLV/FIV? If yes, please provide a date and result.
Submit
Should be Empty: