Geneva Lakes Animal Hospital Pet Exam Form PDF

Client Name
Telephone Number to reach you today:
Has your pet been seen by us?

YesNo (if No please fill out client registration form)
Pet's Name
Breed
Age
What are we seeing your pet for today?
What is the name of the food you are feeding? Is it Wet, dry, or both, How much to you feed at each feeding and how many times per day. What was the time of the last meal.
Was this a new bag of food or have you switched food? (If yes when?)
Does your pet get regular treats? Type and Frequency (include table food)
Please list all the medications or supplements your dog receives and/or recently received. Please list; name of medication, milligram strength, Amount given, frequency, time and date last given
What brand of Heartworm prevention do you use?
Last Given
What brand of flea/tick prevention do you use?
Last Given
Is your pet sensitive or allergic to any medications or food

YesNo
If yes, please list
Cats; Please choose

IndoorOutdoorBoth
Other cats in house

YesNo
Other Cats outside?

YesNo
Other Pets?

YesNo
If yes what kind?
Dogs; Please choose

Fenced in yardExposure to other dogsExposure to other catsExposure to wild animals
If exposure to wild animals, what kind?
Dogs; please choose

Regular walksSwimming in Pond or lake
Please choose Vaccines, bloodwork, heartworm test and procedures your pet has had.

Rabies 1 yearRabies 3 yearLepto (dogs)Distemper 1 yearDistemper 3 yearLyme (dogs)Heartworm testBlood PanelBordetellaLeukemia (cats)FecalDentalUrinalysis
Primary Complaints

VomitingBlood in UrineItchingPainfulDiarrheaCoughingHairlossGrowth/lumpBlood in stoolSneezingLethargicEarsInappropriate UrinationDifficulty BreathingAnorexiaEyesDifficulty UrinatingLameness/LimpingIncreased Thirst
Other Primary Complaint not listed above
Drinking

IncreasedDecreasedNo Change
Appetite

IncreasedDecreasedNo Change
Urination

IncreasedDecreasedNo Change
Defecation

IncreasedDecreasedNo ChangeLoose/WateryHardStraining to go
Weight

IncreasedDecreasedNo Change
In your own words please describe what is going on with your pet. How long has it been going on? Also please let us know of any previous major medical problems, and any history leading up to the current condition
If your pet has any unusual lumps, bumps, wounds, or skin irritation which you would like the doctor to address today, please note the location of each.
Would you like us to?

Treat your pet after examinationCall you with the findings of the examination and an estimate of treatment cost prior to our treating your pet
Additional requests? Any additional Treatments or Vaccinations you would like us to do today?
Are there any medications you would like refilled today? Flea/tick Preventative? Heartworm Preventative
PROFESSSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Geneva Lakes Animal Hospital, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.
Signed

Clear
Date

MonthDayYear
* Please note that if we have not seen your pet before, we will need to be able to contact you regarding your pet's examination prior to starting any treatments.
Please mark what you described above.
Should be Empty: