Medical History/Risk Assessment
This form is intended to help bring to mind conditions or symptoms you may not have noticed or thought important. Your answers help our doctors determine the best treatment plan for your pet. Thank you.
Date
*
-
Month
-
Day
Year
Date
Doctor's Name
Owner's Name
*
First Name
Last Name
Pet's Name
*
Reason for visit/concern:
*
Please list all medications/supplements your pet is currently taking:
*
What parasite control medication do you use (Sentinel Spectrum, Bravecto, Revolution, etc
Do you ever give your pet any over the counter pain reliever (i.e. Aspirin, Tylenol, Advil, Aleve, etc.)?
*
Yes
No
Sometimes
What brand of food do you feed your pet? How much and how often?
*
What protein is in your pet’s food (i.e. chicken, fish, beef, lamb, etc.):
*
Is your pet’s diet grain free?
*
Yes
No
Has your pet been diagnosed with a heart condition or have a history of seizures?
*
Yes
No
Please list any other pets in your household or animals on your property:
Mouth (choose all the apply)
Bad Breath
Loose/Missing Teeth
Difficulty eating/chewing
Red/Swollen Gums
Yellow/Brown crust on gumline
Decreased appetite
Weight loss
Other
Eyes (choose all that apply)
No problems
Vision Loss
Cloudy
Drainage
Rubbing
Other
Ears (choose all that apply)
No problems
Shaking Head
Scratching
Odor
Seems Painful
Hearing Loss
Other
Skin (choose all the apply)
No problems
Scratching
Rash Bumps/Lumps
Hair Loss
Other
Appetite
Normal
Decreased
Increased
Water Intake
Normal
Decreased
Increased
Urination
Normal
Decreased
Increased
Activity
Normal
Decreased
Increased
Mobility
Normal
Decreased
Increased
Coughing
No
Yes
Sneezing
No
Yes
Vomiting
No
Yes
Diarrhea
No
Yes
Itching
No
Yes
Scooting
No
Yes
Does your pet need an Anal Gland Expression today? (additional fee applies):
*
Yes
No
Is your pet's behavior normal? If not, please describe
*
Pain level 0-9 (most painful), where is the pain?
*
Vaccination Status
*
Current
Needed
Previous problems/treatments/surgery:
*
Does your pet: (choose all that apply)
*
Go outdoors
Go to the park/trail
Board/get groomed
Travel with you out of the area
Not applicable
Prescription Refills/Diets needed today:
*
Would you like a nail trim today (additional fee applies):
*
Yes
No
Is your pet microchipped?
*
Yes
No
Unsure
Describe increase
Frequency
I authorize Westlake Animal Hospital to photograph and post photos of my pet(s) on social media.
*
Yes
No
Submit
Should be Empty: