South Putnam Animal Hospital - Pet History Form

Client & Pet Information
Client Name*

First NameLast Name
Email*
example@example.com
Pet Name*
Primary phone number associated with the account*
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone number of person bringing the pet in*
Please enter a valid phone number.Format: (000) 000-0000.
Pet History

Please share your pet's history with us as well as the reason for your visit today.
What brings you in today?*
YesNo
When did it start?*
Does your pet bring anything up/out when coughing and/or sneezing?*
Does it happen at a particular time of day?*
Has your pet been around other animals (new or visiting pets in the home, boarding facilities, groomers, day cares)?*
YesNo
When did it start?*
Describe what comes up when your pet vomits.*
Does it tend to happen at a particular time of day (for example, overnight or after a meal)?*
Are you aware of anything that may have caused the vomiting?*
YesNo
Please bring a fresh (same-day) sample of stool with you to your appointment if possible.
When did it start?*
Is your pet having accidents in the house?*
Please describe the stool (soft-serve ice cream, puddling, liquid, etc.)*
Have you seen any blood or mucus in the stool?*
Are you aware of anything that may have caused diarrhea?*
YesNo
What has changed about your pet's water intake?*
YesNo
Please bring a fresh (same-day) urine sample to your appointment in a clean container. The sample can be refrigerated if it is collected more than an hour before the appointment.
When did the change in urination start?*
Is your pet having urinary accidents in the house?*
If so, are they large amounts or small amounts or urine?*
Please describe what is different about your pet's urinary habits.*
What kind of food (canned, dry, other) does your pet normally eat? Please tell us what brand(s), how much you feed, and how often. We would also like to hear about what kind of treats or table foods your pet likes and how often you feed them.*
YesNo
What has changed about your pet's eating?*
When did you notice the change?*
For pets eating less, have you fed any different foods to try to tempt your pet to eat?*
Is there anything you are aware of that might explain the change?*
YesNo
For pets that go outside, please describe the time they spend and whether they are supervised outside. For cats that go outdoors, are they known to hunt?*
YesNo
Please describe where your pet goes and how often.*
YesNo
Please describe what you do for at-home dental care.*
Is your pet currently taking any medications? If yes, please list all medications, their doses, how often the medication is given, and the last time your pet had the medication(s). *Please include vitamins, supplements, shampoos, and anything non-food that you give your pet.*
YesNo
What flea/tick product(s) do you use? How often?*
When did the pet receive the last dose?*
YesNo
What heartworm product(s) do you use? How often?*
When did your pet receive their last dose?*
Are there any other medical or behavior concerns you would like to discuss?*
Signature*
Today's Date*

MonthDayYear
Date
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Client & Pet Information

Pet History