Patient History Form

Patient History Form

PETCARE Animal Hospital
Client Information
Name*

First Name Last Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Patient Information - Examinations are $65. Does NOT include testing, medications, etc...

Information on the Pet Being Seen
Pet's Name*
Pet's Species*

DogCat
Gender*

MaleMale, NeuteredFemaleFemale, Spayed
Pet's Breed*
Pet's Birthdate - OR -

MonthDay Year
Date
Pet's Approximate Age
Amount Allowed for Today's Visit (This includes the exam, lab tests, medications)*

Do Anything Regardless of FeeUp to $1000Up to $750Up to $650Up to $550Up to $450Up to $350Up to $250Up to $150Up to $100Do NOT do ANYTHING without a phone call
Patient History

Information on the Pet Being Seen
What Are We Seeing Your Pet For? Please be as detailed as possible*
How Long Have the Symptoms Been Going On For?*
When Did You First Notice Something Was Going On?
Has Your Pet Been Previously Seen For This Problem?*

NoYesIt's Been Years
Is Your Pet Currently on Any Medications (Prescription or Over-The-Counter) or Supplements?*

NoYesNot Sure
If Your Pet is on Any Medications, Supplements or Special Diets? Please List Them Below (Including Strength and Frequency)
Example: Rimadyl 25mg - Give ONE tablet by mouth TWICE daily
Vaccination Status - When Was Your Pet Last Vaccinated by a Licensed Veterinarian?*

In the Last YearMore than 1 YearHas Only Received Vaccines by the BreederHas Never Been VaccinatedNeeds Vaccinations Updated Today (Not An Option if Sick)Home Vaccinations Done by Myself
Has Your Pet Had Any Vaccine or Allergic Reactions in the Past (Including Drug Reactions)?*

NoYesNot Sure
General - Symptoms

Information on the Pet Being Seen
Appetite: (Select All That Apply)*

Eating NormallyEating Has IncreasedEating Has DecreasedIs Approaching Food Bowl but Turns Away - Not Eating AnythingAbsolutely No Interest in Food or TreatsNot eating regular diet - able to get pet to eat other things (treats, human food, etc...)
Water Intake: (Select All That Apply)*

Drinking NormallyDrinking Has IncreasedDrinking Has DecreasedAbsolutely No Interest in Water
Activity: (Select All That Apply)*

Regular ActivityActivity Has IncreasedActivity Has DecreasedNot Active Anymore / LethargicHiding
Vomiting: (Select All That Apply)*

None1x Weekly1x MonthlySeveral Times DailySeveral Times Weekly
Bowel Movements / Defecation / Stools: (Select All That Apply)*

Normal Defecation (Stools are Normal Consistency)Stools are Soft but Not Completely DiarrheaDiarrhea - No Blood or MucusDiarrhea - Blood or Mucus PresentNot Defecating at AllStraining or "pushing" to defecate
Urination: (Select All That Apply)*

Normal UrinationStraining to UrinateUrinating Less OftenUrinating More OftenBlood Present in UrineMucus Present in UrineNot Urinating at All
Coughing: (Select All That Apply)*

None SeenSmall Amounts of Coughing SeenCoughing FrequentlyCoughing ONLY after activity / play
Sneezing: (Select All That Apply)*

None SeenSmall Amounts of Sneezing SeenSneezing FrequentlySneezing with Discharge
Ears: (Select All That Apply)*

No Ear ProblemScratching LEFT EarScratching RIGHT EarShaking HeadFoul odor from ear(s)Discharge from ear(s)Swelling on ear(s)
Eyes: (Select All That Apply)*

No Eye ProblemScratching LEFT EyeScratching RIGHT EyeDischarge PresentLEFT Eye Swollen / SquintingRIGHT Eye Swollen / Squinting
Lameness: (Select All That Apply)*

No Lameness FoundFavoring LEFT FRONT LegFavoring RIGHT FRONT LegFavoring LEFT REAR LegFavoring RIGHT REAR LegUnsureKnuckling or Dragging One or More Limbs
Weight: (Select All That Apply)*

Maintaining WeightHas Gained Weight, Rapidly/Quickly - UnintentionalHas Gained Weight, Slowly/Over Time - UnintentionalHas Lost Weight, Rapidly/Quickly - UnintentionalHas Lost Weight, Slowly/Over Time - UnintentionalHas Last Weight, Slowly - Intentional
Questions
Are There Any Questions or Concerns for the Veterinary Nurse or Veterinarian? If so, please list*
Signature*

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Client Information

Patient Information - Examinations are $65. Does NOT include testing, medications, etc...

Patient History

General - Symptoms

Questions