LFPC History Form
Welcome to Lakeville Family Pet Clinic! Please fill out this medical history form prior to your appointment.
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Client and Pet Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Pet's Name
*
Type of Pet
*
Dog
Cat
Breed
*
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Is Your Pet Spayed or Neutered
*
Yes
No
Unsure
When was the Approximate Date of Your Pets Last Heat Cycle?
-
Month
-
Day
Year
Indoor or Outdoor Cat
*
Indoor
Outdoor
Both
For New Patients, what is the name and location of your previous veterinary clinic?
Reason for Visit/ Concerns needing to be Addressed
*
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Is Your Pet on any Preventatives?
*
Yes
No
What Type(s)?
HeartGard
NexGard
NexGard Plus
Other
Where Do You Purchase Your Preventative?
Is the Preventative Given Year Round?
Yes
No
Which Months are the Preventative Given to Your Pet?
i.e. only May-August.
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Noticeable Changes
We consider a change to be noticeable if it has occurred within the past 30 days.
Have You Noticed Any Changes in Your Pets Appetite?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Water Consumption or Thirst?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Urination Patterns?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Defecation Patterns?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Behavior?
*
Yes
No
Explain
Have You Noticed Any Changes in Your Pets Energy Levels?
*
Yes
No
Explain
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Current Diet
*
Include brand name, flavor, amount fed, etc. for all treats and meals
Any Known Medical Conditions or Allergies?
*
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Is Your Dog on Any Current Medication(s)?
*
Yes, 1
Yes, 2
Yes, 3+
No
Name of Medication
Dosage
Include if the medication is given as needed.
When was the Medication Last Given?
Name of Medication 1
Dosage Med 1
Include if the medication is given as needed.
When was Medication 1 Last Given?
Name of Medication 2
Dosage Med 2
Include if the medication is given as needed if applicable.
When was Medication 2 Last Given?
Name of Medication 1
Dosage Med 1
Include if the medication is given as needed.
When was Medication 1 Last Given?
Name of Medication 2
Dosage Med 2
Include if the medication is given as needed.
When was Medication 2 Last Given?
Name of Medication 3
Dosage Med 3
Include if the medication is given as needed.
When was Medication 3 Last Given?
Include Any Other Medications here:
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Behavioral Notes:
Please let us know if your pet is dog-aggressive, bites, dislikes having their feet touched, is anxious, or has any other behavioral concerns. This will help our staff ensure your pet’s appointment is as comfortable and accommodating as possible.
What Can We Do To Make This Appointment Go As Well As Possible For You?
Additional Medical Concerns:
Additional Comments:
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Should be Empty: