Green Cove Pet Hospital - Patient History Form (appt. request>patient history>new client)

1
Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.
2
Owner Information* This field is required.
Owner First Name
Owner Last Name
Please enter your phone
Cell Phone
Landline
Is this a Cell/Landline
Owner Email
3
Health Information
4
Have you or your pet traveled outside of Alabama state in the last 14 days?
YESNO
5
Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?
YESNO
6
Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?
YESNO
7
Pet Information
Pet Name
Pet Breed
8
Has your pet been seen anywhere else since their last visit?
YESNO
9
Where?
10
What is the reason for your visit?
Vaccines/Annual Wellness Exam
Exam
Recheck
Tech Appointment
Medication/Food Pick-up
Other
11
While my pet is here I would like the following
Nail Trim
Dremmel
Anal Gland Expression
Trim feet hair
12
What is the issue?
13
What date did the issue begin?
14
Has your pet had any of the following:(select all that apply)
Coughing
Sneezing
Vomiting
Diarrhea
New lumps or bumps
Behavior Changes
Changes in mobility
15
My pet's appetite has
Decreased
Been Normal
Increased
16
My pet's thirst level has
Decreased
Been Normal
Increased
17
My pet's activity level has
Decreased
Been Normal
Increased
18
My pet's urination has
Decreased
Been Normal
Increased
19
Pet Food
Wet food only
Dry food only
Wet and Dry Mixture
People Food
Raw Diet
Home Cooked Diet
Prescription Diet
My pet eats
20
What brand of pet food?
21
How often is your pet fed?
How much is your pet fed?
Yes
No
I'm not sure
Has your pet's diet changed in the last 6 months?
22
In addition to pet food, what treats or other food does your pet receive? (include any human food, veterinary dental products, bones, rawhides, etc.)
23
Is it possible for your pet to have eaten any of the following?(Select all that apply)
Garbage
Ingested toxins (rat bait, ant bait, other known toxic substances)
Ingested Mushrooms
Ingested Marijuana
Eaten toys (part of toys missing, chewed up etc.)
Eaten grain free diet for any period of time
Ingested human or animal medications not intended for them or at higher doses than intended
None of the above are possible
24
If None of the above are possible, Please tell us more
25
Has your pet had any medications, supplements or topical treatments in the past month?* This field is required.
YESNO
26
Preventatives
27
Is your pet on a heartworm preventative?
YESNO
28
Is your pet on a flea/tick preventative?
YESNO
29
Pet Lifestyle
100% indoors, never goes outside or has access to an open window or outdoor patio
100% indoors, access to open windows and/or an outdoor patio
Indoors with supervised time outside
Indoors with unsupervised time outside
Outdoor with limited indoor access
Outdoor
Is your Pet
Yes
No
Farm Animals
Are there other pets in the house?
30
Does your pet do any of the following?(select all that apply)
Visit the dog park
Get Groomed Regularly
Compete in Dog/Cat Shows
Attend Obedience Training
Attend Agility/Dock Diving
Search and Rescue programs
Board
Attend Doggie Daycare
Travel with you (inside Alabama state)
Travel with you (outside Alabama state)
No
31
Pet Vaccinations
Yes
No
I'm not sure
Is your pet current on vaccinations?
Green Cove Pet Hospital
Another Hospital
I'm not sure
My pet's vaccines were administered last by?
Yes
No
I'm not sure
Does your pet have allergic reactions to vaccinations?
32
Has your pet bitten anyone in the last 15 days?
YESNO
33
Is there anything else we should know about your pet?
YESNO
34
Appointment Procedures
I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.
Should be Empty: