New Patient History Form
Please complete this form if your pet is a new patient.
Pet's Name
*
Owner Name
*
First Name
Last Name
Owner Email
*
example@example.com
Is your pet a dog or a cat?
*
Dog
Cat
Is your pet a male or female
*
Male
Female
Why are you bringing your pet in today?
*
Any coughing or sneezing?
*
Yes
No
Any increase or decrease in urination?
*
Yes
No
Any increase or decrease in water intake?
*
Yes
No
Has your pet had an increase or decrease in appetite?
*
Yes
No
Has your pet had any vomiting or diarrhea?
*
Yes
No
When is the last time your pet ate?
*
Does your pet have any pre-existing medical problems or history of transfusion?
*
Yes
No
Is your pet currently on any medications?
*
Yes
No
If yes what medicines and when was their last dose?
Is your pet current on vaccines?
*
Yes
No
Does your pet have any history of vaccine reactions?
*
Yes
No
Does your pet have any food/medication allergies?
*
Yes
No
Has your pet had any recent boarding or contact with another pet outside your home?
*
Yes
No
Is your pet current on vaccines?
*
Yes
No
Is your pet spayed/neutered?
*
Yes
No
If your pet is not spayed when was her last heat cycle?
Are there any procedures your pet has not liked having performed in the past (nail trims, blood draws, weight, temperature)?
*
Yes
No
If yes, please list the procedures and explain how your pet reacted.
Has your pet been prescribed supplements or medications to decrease anxiety associated with a veterinary visit?
*
Yes
No
If yes what medication and how did they respond?
Does your pet have sensitive areas that they do not like to be touched?
*
Is your pet currently on Heartworm Prevention?
*
Yes
No
If yes, what product?
Is your pet currently on Flea and Tick Prevention?
*
Yes
No
If yes, what product?
When was your pet’s last dose of Flea and Tick Prevention?
*
If a feline:
Indoor
Outdoor
Both
Does your pet share the house with any other cats or dogs?
*
Yes
No
Do they share the house with cat(s), dog(s) or both?
Cat(s)
Dog(s)
Both
How many other cats do you have?
How many other dogs do you have?
What dental care are you providing at home?
*
In the event of an emergency would you like CPR if your pet requires resuscitation?
*
Yes
No
Any additional information you would like us to know?
Submit
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