Veterinary Patient History Form

Patient History Form

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
Species

DogCatOther
Breed
Birthdate or Age
Gender

Male CastratedFemale SpayedMale IntactFemale Intact
Your Name*

First NameLast Name
It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk.
Where can we call you at while your pet is here?*
Email
example@example.com
Referring Veterinarian and Hospital
Reason for your pet's visit today?
This issue began on:
Date
Is there a time of day or activity in which it is worse?
This issue is:
Do any of your pets' genetic relatives have heart disease?

NoYes
If yes, what type?
When was your pets last heartworm test?
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
It is seasonal or year-round monthy?

SeasonalYear-round
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure
Date of last vaccination?
My pet's appetite is:
If increased or decreased, please provide more information:
Weight change?

NormalWeight lossWeight gain
My pet's thirst level is:
My pet's activity/energy level is:
If increased or decreased, please provide more information:
Is your pets breathing normal or abnormal?
Breathing rate while sleeping?
Is there any coughing? If yes, when did it start?
Is the cough associated with activity?
If yes, which activity?
Is the cough associated with a particular time of day? If yes, what time(s)?
Is it a wet or dry cough?

wetdry
Any weakness?

YesNoOther
My pet eats

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.)
Has your pet's diet changed in the last 6 months?

YesNoI am not sure
Has your pet every been on a boutique/exotic/grain free/non-traditional diet containing legumes?

YesNo
Is your pet currently on a raw diet?

YesNo
Is Your Pet:

Indoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightOther
Please list the current medications that your pet is on including dosage, frequency and date it was prescribed.
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?

Please upload if available.
Cancelof
Is There Anything Else You Would Like To Discuss Today?
Signature*

Powered by Jotform SignClear
Should be Empty: