Delton VH - History of Illness

History of Illness

Filling out this form prior to your arrival will allow for a quick and easy drop off!
DATE

Month Day Year
Date
CLIENT INFORMATION
OWNER'S NAME

First Name Last Name
CO-OWNER'S NAME

First Name Last Name
ADDRESS

Street Address

Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER

Area Code Phone Number
SECONDARY PHONE NUMBER

Area Code Phone Number
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME *
SPECIES/BREED *
SEX *
AGE/D.O.B *
Consent to take pictures for social media *
Send claim to insurance? *
Insurance information:
Company, plan number, etc.
What is the primary reason for your visit?
Describe the signs of sickness. Select all that apply:

Pet's activity level is decreased Pet's activity level is increased Pet's appetite is decreased Pet's appetite is increased Decreased water intake Increased water intake Straining to pee Straining to poop Increased urination Vomiting Diarrhea Shaking head Scooting Weight loss Gagging Depression Restlessness Seizures Coughing Sore Ear Discharge from eyes Pain Difficulty breathing Panting Limping Odour Hair loss Change in behaviour Scratching/biting self Growths
Describe in more detail the symptoms marked above:
How long has your pet had these symptoms?
Any other pets in your home affected? If yes, please elaborate
My pet spends time

Inside Outside Both
All vaccines up to date?

Yes No Unsure
Does your pet visit dog parks, groomers, or boarding facilities?

Yes No
Has your pet been on any medications or supplements recently? If yes, please provide the name and frequency of doses:
What food and treats do you feed your pet?
Please list brand and amount given per day.
Have you travelled with your pet recently? If yes, where?
Additional comments or questions:
Should be Empty:

CLIENT INFORMATION

PATIENT INFORMATION