Veterinary Patient History Form

Patient History

Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name*

First NameLast Name
Your Name*

First NameLast Name
Please inculde all of the information requested to the best of your knowledge to allow us to provide quality care for your pet.

If you have hard copy of records please attach to this form as well.
Best phone number and email to reach you at?*

Phone number Email
Reason for your pet's visit today?
This issue began on:
Date
This issue is:
CoughingSneezingVomitingDiarrhea
Color
Texture
Frequency
Consistancy
Duration
YesNo
YesNoI'm not sureType option 4
YesNoI'm not sureType option 4
Color
New lumps or bumpsBehavior changesChanges in mobility
Please Describe Changes
Location of Lumps/Bumps
When Did You Notice Them?
Any Discharge or Odor from Bumps?
My pet's appetite is:
If increased or decreased, please provide more information:
My pet's thirst level is:
If increased or decreased, please provide more information:
My pet's activity level is:
If increased or decreased, please provide more information:
My pet's urination is:
Color
Amount
Frequency
Duration of Abnormal Urination
Wet food onlyDry food onlyWet and Dry MixturePeople FoodRaw DietHome Cooked DietOther
Brand of Pet Food
If prescription diet, what formulation?
How Often Is Your Pet Fed?
How Much Is Your Pet Fed?
In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)
YesNoI am not sure
Eaten garbageIngested toxins (rat bait, ant bait, other known toxic substances)Ingested MushroomsIngested MarijuanaEaten toys (part of toys missing, chewed up etc.)Eaten grain free diet for any period of timeIngested human or animal medications not intended for them or at higher doses than intended?NONE OF THE ABOVE ARE POSSIBLE
Please tell us more:
Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:
When Was Your Pet's Last Dose of Heartworm Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Heartworm Preventative Do You Use?
Name of medication - put unknown if not sure
When Was Your Pet's Last Dose of Flea/Tick Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure
Indoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightOther
YesNoFarm Animals
Please tell us about the other pet's in your home
Visit the dog parkGet Groomed RegularlyCompete in Dog/Cat ShowsAttend Obedience TrainingAttend Agility/Dock Diving/Search and Rescue programs etc.BoardAttend Doggie DaycareTravel with you (inside Ohio)Travel with you (outside of the state)
YesNoI Am Not Sure
At Urbana Veterinary ClinicI Am Not Sure WhereOther
YesNoI Am Not Sure
YesNoI Am Not Sure
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Browse Files
Please upload if available. Cancelof
Is There Anything Else You Would Like To Discuss Today?
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.*
Initial
Clear
Should be Empty:

Patient History

Appointment Procedures