Patient History

1

What is your pet's name and your last name?

2

What is the name of the person bringing your pet to their appointment?

3

What is the primary concern(s) you would like us to address at your appointment?

5

Has your pet had an increase in thirst or urination? Or, is there anything that seems excessive about the volume or frequency? Any urinary accidents?

6

How is your pet's energy and appetite?

7

If needed, please detail any unusual symptoms your pet is experiencing, including the frequency and any other relevant details.

8

Has your pet had any significant behavior changes?

9

Has your pet traveled outside of Oregon? If so, where (generally speaking)?

10

Click all that apply to your pet's lifestyle.

Goes outside (for cats)

Interacts with pets outside of your house

Goes to parks, grooming, boarding, or daycare

Exposure to ticks

Hiking/camping/beachgoing

11

Are there any other pets living with your pet at home? Please specify species.

12

Does your pet have pet insurance?

YESNO

13

Does your pet have a microchip?

YESNO

14

What brand and formula of food does your pet eat? What how many cups/cans are you feeding per day?

15

Is your pet on any medications, supplements, or vitamins? Please list them using this format - drug name, pill size (mg) or liquid concentration (mg/ml), and frequency given - let us know if you need a refill and we will get it ready Example: Benadryl 25mg capsule: 1 by mouth every 12 hours

16

Is your pet currently on flea, tick, or heartworm prevention? If so, please list the name of the medication(s) and the last dose given

17

Are there any other concerns you would like us to discuss at your appointment?

18

Let us know if we need to acquire records from any other veterinary clinic, specialist, or emergency hospital prior to this appointment.

19