Patient History
Please answer each question to the best of your ability. By filling out this patient history form ahead of time, you can help us to better prepare for your pet's visit and streamline the exam room experience.
Client Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Patient Name
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Species
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Canine (Dog)
Feline (Cat)
Age
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Sex
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Please Select
Male
Female
Male Neutered
Female Spayed
Unknown
Date of Appointment
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Month
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Day
Year
Date
What type of appointment is your pet scheduled for?
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Wellness/Annual Preventive Care (adult)
Puppy Wellness/Preventive Care
Kitten Wellness/Preventive Care
Problem-focused Visit
Is this your puppy's first visit with us?
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Yes
No
Is this your kitten's first visit with us?
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Yes
No
Wellness/Annual Preventive Care Visit history
Puppy Wellness/Preventive Care
Kitten Wellness/Preventive Care
Problem-focused Visit
If your pet is scheduled for a Wellness/Preventive Care Visit in addition to addressing a specific problem, please fill out the Wellness/Preventive Care history form instead of this one.
Please check your selections and try again.
You may have chosen mixed-species options, such as choosing "Canine" and then "Kitten Wellness/Preventative Care"
Does your pet have any chronic medical conditions or long-standing issues? Has your pet been to another veterinarian or had any major illnesses or surgeries since the last time we saw them?
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If your pet has been to another veterinarian since the last time we saw them, please list the name/location of the clinic, as well as any other client/patient name they may be listed under.
Please describe why you are bringing your pet to the veterinarian. What symptoms or behaviors are you concerned about?
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If your pet is having soft/loose/watery stool, please bring a stool sample with you to the appointment. If your pet is having urinary symptoms, please do not allow your pet to urinate for 2-3 hours prior to the appointment if possible.
When did you first notice the issue(s)? Have you noticed any improvement or worsening of the issue(s), or is it about the same?
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Have you attempted to treat the issue(s)? If so, please describe the treatment(s) you have tried (include the name/brand of any medications/topicals, duration and frequency of treatment, and whether you noticed any improvement or worsening of the issue(s) during treatment).
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Where did you get your puppy (shelter, breeder, Facebook ad, found, etc)? How long have you had your puppy?
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Where did you get your kitten (shelter, breeder, Facebook ad, found, etc)? How long have you had your kitten?
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If we administered vaccinations at your pet's last visit, did you notice any issues afterwards?
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Mild lethargy (tiredness/lack of energy) and mildly decreased appetite are considered normal post-vaccination and should resolve within 24 hours.
Please describe your pet's appetite/eating habits. Have there been any changes, and if so, how long ago did you notice a difference?
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Please describe your pet's water intake. Have there been any changes, and if so, how long ago did you notice a difference?
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Has your pet experienced any vomiting? If yes, how often and for how long have you noticed an issue? What does the vomit look like (foam, undigested food, partially digested food, etc)?
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Has there been any change or abnormality in your pet's urination and/or defecation habits (soft/loose stool, diarrhea, difficulty passing stool, etc)? If yes, please describe the change(s) or abnormality and how long ago you noticed it.
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Has your pet experienced any unusual or persistent coughing and/or sneezing? If yes, please describe frequency and whether the cough/sneeze is productive (does the pet bring up phlegm or mucous, does it have a color, etc).
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Have you seen any worms in your pet's stool or around their bottom? If yes, did they look like grains of rice? Have you noticed your pet scooting their bottom on the ground or licking the area excessively?
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Does your pet have any skin issues or seem itchier than normal? Have you noticed them licking their feet or rubbing themselves on furniture/carpeting? If so, how long has it been since you first noticed it?
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Have you noticed any new growths, lumps on or under the skin, skin tags, etc? If so, please note the location, how long it's been since you first noticed it, and whether it has changed at all since.
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Have you noticed any new behavioral issues (anxiety - in general, over being left alone, storms, other loud noises, etc; aggression or resource guarding; pacing; loss of housetraining; any other behavior that affects quality of life)? If yes, please describe the behavior and how long ago you began noticing it.
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Describe your dog's mobility. Do they run, jump, and play like they always have? Have you noticed any limping, stiffness, slowness, reluctance to jump up/down or use stairs? Do they seem painful or do they vocalize (yelp/whine) when moving around or when you pet them in a certain area?
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This checklist can be helpful in assessing your dog's mobility.
Describe your cat's mobility. Do they run, jump, and play like they always have? Have you noticed any limping, stiffness, slowness, reluctance to jump up/down or use stairs? Do they seem painful or do they vocalize (yowl/hiss) when moving around or when you pet them in a certain area?
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This checklist can be helpful in assessing your cat's mobility.
Do you have any concerns about your pet's eyes? Have you noticed any discharge, redness, or squinting, or your pet pawing at their eye(s)? Have you noticed any vision changes (bumping into things, wariness in low light conditions, unable to catch treats like they used to)? If so, how long has it been since you first noticed the issue?
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Do you have any concerns about your pet's ears? Have you noticed any discharge or odor, or your pet scratching at them more than normal? If so, how long has it been since you first noticed the issue?
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Do you have any concerns about your pet's mouth? Do they seem to chew their food normally, without dropping it or turning their head to one side or the other? If you have noticed anything abnormal, how long has it been since you first noticed an issue?
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Describe your pet's diet. Include brand/variety of food, form (dry/canned/other), how much and how often they are fed (or if food is left out all the time). List any treats they receive, including dental chews, rawhide, etc and how much/how often. If they get people food, please describe what, how much, and how often they receive it.
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How much time does your dog spend outdoors? Please describe how they spend their time outdoors - on a screened-in porch, on a leash, in a fenced yard (physical or invisible), on a tether, free to go where they want (supervised or unsupervised).
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Have there been any changes in your pet's lifestyle or in your household since the last visit?
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We assessed your pet's lifestyle risks during their first visit. This question is checking to see if there have been any changes that would indicate we need to revisit their risk factors. Have you added a new pet, moved, or decided the pet is going to spend more time outdoors? Have you decided to sign your dog up for daycare or puppy classes?
What other pets are in the household? Please include all pets that reside on the property, even if they do not belong to you or live purely outside while your pet is purely inside or vice versa.
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Do you or your neighbors own livestock (cattle, horses, goats, pigs, chickens, etc.)? Do you have wildlife around your home (rats, mice, squirrels, groundhogs, chipmunks, deer, foxes, raccoons, opossums, etc.)? Do you take your dog hiking, camping, or to the dog park? Is your dog around bodies of water (pond, creeks, marshlands), even if they don't swim or drink from them? Does your dog travel? If none of these situations currently apply, do you anticipate that changing in the next year?
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This question assesses your dog's risk of contracting leptospirosis, a serious and potentially life-threatening disease that is transmitted in the urine of livestock and wildlife. It does not require direct contact with infected animals, only access to areas where their urine may be present. Leptospirosis is also a zoonotic disease, meaning it can be transmitted to (and infect) humans.
Patient Lifestyle & Risk Assessment: Leptospirosis. Please check all that apply to your dog’s routine and environment:
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Shared Spaces: Walks in neighborhood parks, communal grassy areas, or apartment complex "dog runs." Visits dog parks, even if other dogs aren't present at the same time.
Backyard Access: Spends time in a private backyard (fenced or unfenced) where squirrels, raccoons, opossums, deer or other wildlife are known to visit—even if your pet never comes into direct contact with them.
Nature & Trails: Accompanies family on hiking trails, camping trips (tent, cabin, or RV), or visits to wooded areas, nature trails, or the Battlefield.
Water Exposure: Has access to (or interest in) slow-moving water, creek beds, ponds, or areas where puddles frequently collect after rain.
Wildlife Attractants: Your property or neighborhood has bird feeders, fruit trees, or vegetable gardens that may attract nocturnal visitors.
Farm & Livestock Exposure: Lives on or visits property with livestock (cattle, horses, goats, chickens, etc.) or areas where livestock manure/runoff may be present.
Travel: Has traveled (or plans to travel) outside the immediate area. This includes stopping at highway rest areas while driving or visiting high-risk regions, such as Florida, Louisiana, or the Gulf Coast, where Leptospirosis is significantly more prevalent.
Future Lifestyle Changes: You anticipate a change in the next 12 months that may increase exposure, such as upcoming travel to the coast, moving to a new home with more wildlife/wooded acreage, or starting outdoor hobbies like hiking or camping.
None of these options apply.
Patient Lifestyle & Risk Assessment: Bordetella (Kennel Cough). Please check all that apply to your pet’s routine and environment:
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Professional Care & Grooming: Regularly visits a professional groomer, utilizes doggy daycare, or stays at a boarding kennel.
Training & Competition: Attends obedience classes, participates in dog shows, agility, or hunt trials where numerous dogs from different households congregate.
High-Traffic Social Areas: Visits public dog parks, "pet-friendly" retail stores, or communal areas in apartment complexes where nose-to-nose contact with other dogs is common.
Rescue & Foster Work: Your household fosters dogs for a rescue, shelter, or humane society, or you frequently interact with newly adopted pets.
Public Events: Accompanies the family to festivals, farmers' markets, or outdoor patios where they may encounter unfamiliar dogs.
Future Plans: You anticipate any of the above situations changing within the next 12 months (e.g., upcoming vacation, new puppy class, or switching to a professional groomer).
None of these options apply.
Has your cat ever been tested for Feline Leukemia and Feline Immunodeficiency Virus? What were the results? How long ago was the test done?
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How much time does your cat spend outdoors (or do you anticipate them spending outdoors in the future)? Please describe how they (may) spend their time outdoors - on a screened-in porch or catio, on a leash, in a fenced yard, free to go where they want (supervised or unsupervised). Are there other cats that spend time outside in the neighborhood (whether owned or stray)? Do you see/hear evidence that your cat fights with other cats (whether owned or stray)?
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This question assesses your cat's risk of contracting Feline Leukemia and/or Feline Immunodeficiency Virus. Both viruses are transmitted via bodily fluids exchanged during risky behavior such as fighting and mating. Both viruses are also life-long once infected, and infection can result in serious medical consequences. Cats that are at high risk for contracting these viruses should be tested annually, and all cats that have contact with cats of unknown status (or cats that live with cats that have contact with cats of unknown status) should be kept up-to-date on Feline Leukemia vaccinations. Unfortunately, there is no reliably effective vaccination for Feline Immunodeficiency Virus.
Do you have any plans to board your dog at a kennel? Does your dog go to doggy daycare or the dog park? How often does your dog visit the groomer? Does your dog go to obedience classes, dog shows, hunt trials, or any other venue/event where there are numerous other dogs in attendance? Do you foster dogs for a rescue, shelter, or humane society? If none of these situations currently apply, do you anticipate that changing in the next year?
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This question assesses your dog's risk of contracting "kennel cough". Kennel cough is a catch-all term for the myriad of respiratory diseases that dogs are susceptible to that are similar to whooping cough in people. Kennel cough can be caused by many different bacteria/viruses, and as such, vaccination isn't always 100% protective. However, vaccination can prevent some disease, and often will lessen the severity of an infection when it does happen. Dogs that congregate with others, especially in enclosed areas, are at the highest risk of contracting kennel cough.
What are you currently using to prevent fleas and ticks? Are ticks an issue in your yard?
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What are you currently using to prevent heartworm infection? When was the last time your pet received a dose? Does your pet receive heartworm prevention year-round (12 months a year)? Is there anything you wish were different about the heartworm prevention you are using (easier to give, longer-lasting, covered more parasites)?
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What are you currently using to prevent heartworm infection? When was the last time your pet received a dose?
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Please list any medications or supplements (prescribed or over-the-counter) your pet is receiving. Include the name/brand, dosage, route (by mouth, topical, eye drop, ear wash, etc) and how often.
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Is there anything else that you would like us to know about, or anything specific you would like checked that hasn't already been covered?
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