Patient History

1

Please fill this out in it’s entirety and thoroughly. Please avoid giving single word answers if your pet if coming for a medical concern.

2

Client Name* This field is required.

First Name

Last Name

3

Patient Name: Patient Name *

4

Best Phone Number for you at this appointment:* This field is required.

Area Code

Phone Number

5

What is the primary reason for your visit?* This field is required.

6

How long have the symptoms been going on?

7

Are there any other pets in the household affected?

8

Did any diet change/medication administration precipitate the concerning behavior?

9

Any Vomiting?* This field is required.

Yes

No

10

Vomiting: If yes, please describe (How often, any certain time of day etc)

11

Any diarrhea?* This field is required.

Yes

No

12

Diarrhea: If yes, please describe (How often, any certain time of day etc)

13

Any coughing?* This field is required.

Yes

No

14

Coughing: If yes, please describe (How often, any certain time of day etc)

15

Any sneezing?* This field is required.

Yes

No

16

Sneezing: If yes, please describe (How often, any certain time of day etc)

17

Any change in activity level?* This field is required.

Yes

No

18

Activity Level: If yes, please describe (How often, any certain time of day etc)

19

Any change in water intake?* This field is required.

Yes

No

20

Water Intake: If yes, please describe (How often, any certain time of day etc)

21

Any itching?* This field is required.

Yes

No

22

Itching: If yes, please describe (How often, any certain time of day etc)

23

What Heartworm Prevention do you currently have your pet on?* This field is required.

Ex. Advantage Multi, Trifexis, Simparica Trio, ProHeart etc.

24

What Flea and Tick Prevention is your pet on?* This field is required.

Ex. Simparica, Bravecto, Advantage II, Seresto Collar

25

Please list all Supplements your pet is currently on?* This field is required.

Ex. Daily Vitamin (Pet Vites), Joint Supplement (Movoflex)

26

Please list all medications your pet is currently on?* This field is required.

27

What food are you currently feeding your pet? Please list anything your pet gets by mouth.* This field is required.

Ex. Dog food, yogurt, carrots, pumpkin etc.

28

Do you travel with your pet?* This field is required.

Yes

No

29

Have you seen fleas recently on your pet?* This field is required.

Yes

No

30

Have you seen any ticks on your pet?* This field is required.

Yes

No

31

Do you board your pet?* This field is required.

Yes

No

32

Do you take your pet to the groomer?* This field is required.

Yes

No

33

Do you live in a multi-home community? (Ex. apartment complex)* This field is required.

Yes

No

34

Is this patient a cat or dog?* This field is required.

Cat

Dog

35

Dogs: Do you take your pet by the lake/ocean/rivers?* This field is required.

Yes

No

36

Dogs: Do you frequent dog parks or doggy daycares?* This field is required.

Yes

No

37

Dogs: Do you take your dog hiking/camping?* This field is required.

Yes

No

38

Cats: Does your cat stay indoors 100% of the time?* This field is required.

Yes

No

39

Cats: Does your household contain more than one cat?* This field is required.

Yes

No

40

Cats: If you have more than one cat, are the others currently vaccinated?* This field is required.

Yes

No

I only have 1 cat

41

Cats: If your household has more than 1 cat, do any of them go outside at any point?* This field is required.

Yes

No

I only have 1 cat

42

Do you bring new animals into your home as fosters or do you volunteer with a rescue and have contact with their animals?* This field is required.

Yes

No

43

Is there anything else we should know?* This field is required.

Yes

No

44

If yes, please describe (How often, any certain time of day etc)

45

Please know, to diagnose your pet, it may be necessary to do further diagnostics.

46

Can we run bloodwork if necessary?* This field is required.

Yes

No

Call First

47

Can we take radiographs if necessary?* This field is required.

Yes

No

Call First

48

Some pets require sedation for adequate physical exam and or treatment.

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I also authorize the use of appropriate anesthetics, and other medications, including those for pain, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

49

Can we sedate your pet, given the above risks, if necessary?* This field is required.

Yes

No

Call First

50

At this time, we are asking if you pay in cash that you pay with exact change or allow us to leave the change as a credit on your account. We do not accept checks.

51

Our Social Media is the best way to stay up to date with things happening in the clinic. Are you following us?

Facebook

Instagram

52

Please answer the following:

I grant to Animal Health Care Center, it’s representatives and employees to take or use photographs of me and/or my pet, and to copyright, use and publish the same electronically on Instagram and Facebook.

I agree that Animal Health Care Center may usesuch photographs of me and/or my pet with or without my name and for any lawfulpurpose, including, for example, “Pet of the Week” or Web content.

53

Please call us at 817-467-6688 select option 3 or Text us if you have any questions.