Green Prairie Pet Medical History Form

1
Location* This field is required.
Lincoln
Sherman
San Jose
2
Owner Name & Phone Number:* This field is required.
First & Last Name
Phone Number
3
Pet's Name:* This field is required.
4
Sex* This field is required.
Male
Female
5
Spayed/Neutered?* This field is required.
YESNO
6
Have you noticed any of the following issues with your pet? (Check all that apply):* This field is required.
Increase in appetite
Decrease in appetite
Increase in drinking
Decrease in drinking
Weight gain
Weight loss
Itching/scratching
Shaking head
Bad breath
Vomiting
Diarrhea
Urination issues
Excessive sleeping
Scooting
Difficulting getting up
Lumps or bumps
Car Sickness
Issues with behavior
Other
7
Please tell us how long your pet has been experiencing these symptoms:
8
Has your pet ever had an adverse reaction to a medication, vaccine, or procedure?* This field is required.
Yes
No
9
If you answered yes to your pet having had an adverse reaction to a medication, vaccine, or procedure, please specify below:
Huge
Large
Normal
Small
Ok
Ok
10
What brand & type of food is your pet on?* This field is required.
11
How much do you feed your pet?* This field is required.
Please Select
Please Select
Free fed (food is always offered)
Measured (please specify)
If measured, please specify details
12
Is your pet on any medications?* This field is required.
Yes
No
Any natural or homeopathic items given to your pet? (If so, specify on the next page)
Other
13
Please specify any natural or homeopathic medications given to your pet:
Huge
Large
Normal
Small
Ok
Ok
14
Do you give your pet heartworm medication?* This field is required.
If yes, please specify what product is given or N/A if none is given
15
Do you give your pet flea preventative?
If yes, please specify which product
16
Does your pet come into contact with other pets? Please select all that apply:* This field is required.
None
Grooming
Boarding
Dog Parks
Yes, I have other pets
Other
17

FEAR FREE QUESTIONS

Our hospitals pride ourselves on being Fear Free. This means that we take special things into consideration when your pet comes in for a visit. Please answer the questions below so that we may make the proper accomodations for your pet.
18
When my pet goes to the vet, he's
Eager & Excited
Subdued
Reluctant
Terrified
19
At the vet clinic, my pet doesn't like:
Getting weighed
Getting on the exam table
Having his temp taken
Being handled by the staff
20
Does your pet mind being around other animals or people in the waiting room?
Yes
No
21
My pet prefers:
Female Vets & staff
Male Vets & staff
Anyone who sweet talks him & gives him treats
22
Does your pet enjoy getting into the carrier or car?
Yes
No
23
During the car ride, does your pet do any of the following?
Whine
Bark/meow
Pant
Pace
Drool
Tremble
Pee/Poop
None, my pet loves car rides!
24
Does your pet dislike having it's paws, mouth, ears, or any other body part examined?
Yes
No
25
Any other questions, concerns, or requests?
26
Any previous records? If so, you can upload those here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Signature* This field is required.
Clear
Should be Empty: