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

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

Dog Cat
Gender *

Male Male, Neutered Female Female, Spayed
Pet's Breed *
Pet's Birthdate - OR -

Month Day Year
Date
Pet's Approximate Age
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? *

No Yes It's Been Years
Is Your Pet Currently on Any Medications (Prescription or Over-The-Counter) or Supplements? *

No Yes Not Sure
If Your Pet is on Any Medications or Supplements, 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 Year More than 1 Year Has Only Received Vaccines by the Breeder Has Never Been Vaccinated Needs 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)? *

No Yes Not Sure
General - Symptoms

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

Eating Normally Eating Has Increased Eating Has Decreased Is Approaching Food Bowl but Turns Away - Not Eating Anything Absolutely No Interest in Food or Treats Not eating regular diet - able to get pet to eat other things (treats, human food, etc...)
Water Intake: (Select All That Apply) *

Drinking Normally Drinking Has Increased Drinking Has Decreased Absolutely No Interest in Water
Activity: (Select All That Apply) *

Regular Activity Activity Has Increased Activity Has Decreased Not Active Anymore / Lethargic
Vomiting: (Select All That Apply) *

None 1x Weekly 1x Monthly Several Times Daily Several Times Weekly
Bowel Movements / Defecation / Stools: (Select All That Apply) *

Normal Defecation (Stools are Normal Consistency) Stools are Soft but Not Completely Diarrhea Diarrhea - No Blood or Mucus Diarrhea - Blood or Mucus Present Not Defecating at All
Urination: (Select All That Apply) *

Normal Urination Straining to Urinate Urinating Less Often Urinating More Often Blood Present in Urine Mucus Present in Urine Not Urinating at All
Coughing: (Select All That Apply) *

None Seen Small Amounts of Coughing Seen Coughing Frequently Coughing ONLY after activity / play
Sneezing: (Select All That Apply) *

None Seen Small Amounts of Sneezing Seen Sneezing Frequently
Ears: (Select All That Apply) *

No Ear Problem Scratching LEFT Ear Scratching RIGHT Ear Shaking Head
Eyes: (Select All That Apply) *

No Eye Problem Scratching LEFT Eye Scratching RIGHT Eye Discharge Present LEFT Eye Swollen / Squinting RIGHT Eye Swollen / Squinting
Lameness: (Select All That Apply) *

No Lameness Found Favoring LEFT FRONT Leg Favoring RIGHT FRONT Leg Favoring LEFT REAR Leg Favoring RIGHT REAR Leg Unsure
Weight: (Select All That Apply) *

Maintaining Weight Has Gained Weight, Rapidly/Quickly - Unintentional Has Gained Weight, Slowly/Over Time - Unintentional Has Lost Weight, Rapidly/Quickly - Unintentional Has Lost Weight, Slowly/Over Time - Unintentional Has 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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Should be Empty:

Client Information

Patient Information

Patient History

General - Symptoms

Questions