Best Care Pet Hospital Client History Form

Client History Form
Client Information
Name*

First NameLast Name
Owner #2 Name

First NameLast Name
Pet Name*
How long have you owned you pet?*
Where did you obtain your pet?*
Did your pet have any major problems as a puppy or kitten?*

YesNo
If yes, please briefly explain:*
When was she/he last vaccinated?*
Which vaccines were included?*
Does your pet take heartworm prevention?*

YesNo
If yes, which prevention is your pet on?*
Does your pet receive flea or tick control?*

YesNo
If yes, which flea/tick control is your pet on?*
Do you have any other pets?*

YesNo
How many, and what types of pets do you have?*
What does your pet routinely eat?*
Do you provide any treats or snacks?*

YesNo
What types?*
Where does your pet live?*

IndoorsOutdoorsBoth
Has your pet traveled*

YesNo
Where?*
If your pet is a female, did she have a heat cycle prior to her spay?

YesNo
Has your pet ever been hospitalized?*

YesNo
What For?*
Has your pet experienced any adverse reactions to foods or medications?*

YesNo
What kind of food or medication? What happened?*
Are you able to give your pet liquid medications?*

YesNo
Pills?*

YesNo
Please check all boxes that your pet has experienced now or in the past:

CoughDifficulty BreathingOcular DischargeIncreased AppetiteWeight GainVomitingChange in Stool ColorLamenessSeizuresConfusionItchingBruisingAny MassesSneeseFast BreathingNasal DischargeDecreased AppetiteWeight LossDiarrheaPain AnywhereChange in ActivityFaintingChange in BehaviorLoss of HairChange in Skin Color
Please List All Current Medications
Signature*

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Today's Date*

MonthDayYear
Date
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Client History Form

Client Information