Pet Health Form
Name
First Name
Last Name
Pet's Name
Species (dog or cat)
Main reason for visit
Previous medical problems we should know about:
Current medications/supplements (name of medication and how much/how often you are giving):
Do you need a refill?
Yes
No
What kind of food do you feed?
How much per day?
Which heartworm prevention is your pet currently on?
Do you need a refill?
Yes
No
Which flea and tick prevention is your pet currently on?
Do you need a refill?
Yes
No
How has your pet’s appetite been?
Normal
Increased
Decreased
Not At All
How has your pet’s water intake been?
Normal
Increased
Decreased
Not At All
Has your pet been vomiting? (if so when did it start, how often, and when was the last time)
Has your pet had any diarrhea? (if so when did it start, any blood or mucous, describe consistency)
Has your pet been:
Coughing
Sneezing
Had a Runny Nose
If your pet has had a runny nose, for how long?
Has your pet had any of the following eye problems?
Discharge
Squinting
Redness
Rubbing
When did it start?
Which eye? (or both)
Has your pet been scratching at their ears?
Any Odor?
Shaking Head?
Has your pet had any skin problems?
Has your pet had any skin problems?
Scratching or Licking?
Odor?
Hair Loss?
Sores
Has your pet been urinating normally and outside/in litterbox (cat)?
Any history of seizures?
How Often?
How long?
Any Growths or Lumps?
Location?
How long?
Has your pet been limping? Which leg?
Left
Right
Both
How long?
Any known Injuries?
Do you have any other pets in the house?
Dogs
Cats
Other
If yes, how many of each?
Any other concerns or questions for the Doctor today?
Please verify that you are human
*
Submit
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