Patient History Form

Patient History Form

When you arrive at the hospital, please park in a numbered parking spot. Call us with your pet's name and last name, and which parking spot you are parked in. If our lobby is busy, you may be asked to wait in your car to avoid overcrowding and creating a stressful environment for your pet and other patients. If you choose to remain in your car during your pets exam, the doctor will come out to your car once your pet has been examined. Masks are encouraged but not required. Filling out this form ahead of your appointment helps staff prepare for your visit at Tabernacle Animal Hospital.
Owner's Name*

First NameLast Name
Pet's First Name*
Phone number to be reached at for today's visit*
The reason for your visit:*

Vaccines / Annual Wellness ExamWellness ExamRecheckSick/InjuredTechnician AppointmentOther
Is your pet currently on any medications/supplements? What are they? Please include DOSAGE and FREQUENCY with which medications/supplements are given*
What is the brand of food you are feeding your pet? What is the quantity you feed daily? (ex. 1 cup twice daily)*
Can we give your pet a treat while they are in the hospital? Does your pet have any food allergies we should be aware of?*
Check all that apply:*

My pet is indoor onlyMy pet goes outdoors for walks but spends most time indoorsFrequently outdoorsFrequently outdoors with contact to other petsMy pet visits a grooming facilityMy pet visits dog parksI sometimes board my pet at a boarding facilityOther
Does your pet have any of the following issues?*

CoughingLabored breathingLimpingLethargyIncreased thirstIncreased urinationDiarrheaVomitingItching skin or earsAccidents inside the homeMy pet is healthy, no known issuesOther
Is your pet on a Flea/Tick preventative?*

NexgardSimparicaSimparica Trio (does both flea/tick and heartworm)Seresto CollarRevolutionFrontlineCredelioYes, but unsure which productOther
Is your pet on Heartworm prevention?*

Proheart 12 (injection that lasts for 12 months)Heartgard PlusSentinel SpectrumSimparica Trio (does both flea/tick and heartworm)Interceptor+yes, but unsure which productOther
Does your pet need any of the following during this visit?*

Flea/Tick preventionHeartworm preventionMedication RefillsPrescription FoodNail TrimAnal Gland ExpressionEar CleaningNone Of The AboveOther
Does your pet have any behavior problems? Ex. Doesn't like men, deaf, blind, dog aggressive...*
Are there any other questions or concerns for your doctor? *
Please select all that apply. We will make accommodations to see your pet safely.*

I have been experiencing cold/flu symptoms.I have traveled out of the country in the last 30 days.I have been exposed to COVID-19 or someone with it.None of the aboveOther
Is your pet covered by insurance?*

YesNo
If YES, which insurance is your pet covered under? (if no, please type "N/A")*
Is your CAT exhibiting any of these signs? Check all that apply*

This patient is not a cat"Bunny Hopping" up stairsDescending slowly or at an angle down stairsLays on side, slows down, or takes breaks when playing with toysHesitates when jumping up and/or doesn't fully clear the jumpHesitates when jumping down and/or makes smaller jumps (EX: when jumping down from counter, jumps onto chair first, then the floor)Moves slower/alternates jogging and walkingMy cat does not exhibit any of these signs.unsure
Is your DOG exhibiting any of these signs? Check all that apply*

This patient is not a dogLimping after exerciseDifficulty jumpingLagging behind on walksFeeling stiffSlow to riseDifficulty with stairsMy dog is not exhibiting any of these signsunsure
Do we have consent to take/post pictures of your pet on our social media?*

YesNo
Have a picture of your pet that you would like shared on our wall of patients in the lobby? Attach a picture!

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