PATIENT HISTORY FORM
*If you are coming for boosters and have filled this form out recently you don't need to fill it out again. Thank you
Full Name
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First Name
Last Name
Pets Name
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Phone Number
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Format: (000) 000-0000.
Please enter Diet and Feeding information.
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What parasite risk factors is your dog* exposed to throughout the year?
Has been or plans to be boarded
Goes to dogs parks or high traffic dog areas
Catching or consuming wildlife, ability to scavenge off leash in wildlife populated areas
Exposure to areas with wildlife where they explore on or off leash
Walk or play in parks, picnic areas, campgrounds, hiking areas
Does your cat* ever explore the outdoors?
No, would never leave the comforts of home
Occasional escape artists but regrets decision quickly
Will explore supervised in a secure area
Born to wonder and spends a lot of time outside during their preferred season(s)
Can barely convince them to come back inside
Check the conditions that apply to your pet.
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Coughing
Sneezing
Vomiting
Diarrhea
Eye Discharge
Dirty/Itchy Ears
Nasal Discharge
Limping
Skin Issue
New or changed lump
No concerns
Other
How long has this condition been going on for and with what frequency?
Has your pet experienced this condition in the past?
Please Select
Yes
No
Check the symptoms that your pet is currently experiencing:
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Not eating
Trouble breathing
Trouble Defecating
Trouble Urinating
Weight gain
Weight loss
Change in behavior
Change in activity level/mobility
No concerns
Changes in sleep habits
Other
How long has this symptom been going on for and with what frequency?
Has your pet experienced this symptom in the past?
Please Select
Yes
No
Please list all medications/vitamins/supplements/preventatives that your pet is currently taking.
Has your pet ever had a reaction to vaccinations?
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Yes
No
Not Sure
Do you have tick concerns for your pet currently?
Yes
No
Unsure
Are there any other issues/concerns that you would like to discuss at your appointment?
What is your pets favourite toy/activity?
What is the nickname you use the most for your pet?
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