New Patient History
Pet Name
*
Client Name
*
First Name
Last Name
Species
*
Canine
Feline
Environment
*
Indoor
Outdoor
Indoor / Outdoor
Does your pet hunt rodents or other wildlife?
*
Yes
No
Has your pet ever traveled outside the state of Maine?
*
Yes
No
Where and when?
What was your pet's age when you obtained them?
*
Age (indicate if estimated)
Where did you obtain your pet?
*
Shelter/rescue
Breeder
Stray
Other
Where was your pet obtained?
What is your pet's current diet? Please be as specific as possible.
*
How much does your pet eat per day?
*
Are vaccines up to date?
*
Yes
No
Unsure
When was your pet last vaccinated?
Is your pet on any monthly preventatives? (Heartgard, Nexgard, Revolution plus, advantage multi, etc.)
*
Yes
No
Which type, and when did they receive their last dose?
Are preventatives given seasonally or year-round?
Seasonally
Year-round
Is your pet on any prescription medications?
*
Yes
No
List the name of the medication, strength (mg, mg/mL, units, etc), how much you give (full tablet, 1/2 tablet, etc) and how often you give the medication. This information should be on the medication. If unsure, bring medication to the appointment.
Is your pet on any over the counter medications or supplements ?
*
Yes
No
Which medication/supplement? How often are you giving it?
What concerns do you have for your pet that you would like to address at their appointment?
*
When did the problem(s) begin?
*
Other than the concern(s) listed above, please list other current or past medical problems or surgeries:
Has your pet (if female) ever been pregnant?
Yes
No
Unsure
Has your pet ever received a transfusion of blood, plasma, or other products?
*
Yes
No
Unsure
When?
Do you have other animals in the home environment?
*
Yes
No
What species and how many?
Does your pet go to dog parks, daycare, or a boarding facility?
*
Yes
No
When was your pet last at a dog park, daycare, or boarding?
Please specify approximate date and type of facility
Has your pet exhibited any of the following signs?
Vomiting
*
Yes
No
How often are they vomiting?
How long has the vomiting been going on?
Diarrhea
*
Yes
No
How often does the diarrhea occur? When did it begin?
Coughing
*
Yes
No
How often does coughing occur? When did it begin.
Gagging/retching
*
Yes
No
How often does gagging/retching occur? When did it begin?
Increased sneezing
*
Yes
No
How often does sneezing occur? When did sneezing increase?
Seizures
*
Yes
No
When was the last seizure?
Weight Gain
*
Yes
No
Weight Loss
*
Yes
No
Abnormal breathing
*
Yes
No
Please provide additional details on abnormal breathing:
Decreased activity
*
Yes
No
When did you notice activity levels were lower than normal?
Limping
*
Yes
No
On which limb? How long have they been limping?
Pain
*
Yes
No
Unsure
What signs of pain are noted?
Appetite
*
Normal
Decreased
Increased
What percentage of their normal amount do you estimate they are currently eating?
Drinking
*
Normal
Decreased
Increased
When did drinking habits change?
Urinary habits
*
Normal
Abnormal
Urination frequency
Normal
Increased
Decreased
Urine volume
Normal
Increased
Decreased
When did their urinary habits change?
Is there anything else that you would like us to know before your pet's visit?
Submit
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