New Patient History

New Patient History

Please complete the patient history below. Either submit electronically, or you can print and mail the completed form: Veterinary Wellness Center 9970 Harrison Avenue Harrison, Ohio 45030
Name*

First NameLast Name
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Pet's Name*
Birth date if known, approximate date if not known*
Species*

CanineFeline
Gender*

MaleFemale
Neutered? (Spayed or Castrated)*

yesno
Breed*
Is your pet on any medications?*

YesNo
Please list drugs and dosages:
Does your pet take nutritional supplements?*

YesNo
Please list products and dosages:
Please describe your pet's diet (brands, quantities, frequency). Please include 'people food' that you regularly share with your pet.*
Please list the types of treats that your pet receives and how many per day:*
We would like to know how you heard about our special services, or who referred you to us:
What is/are the current problem(s) that prompted this appointment?*
Please provide the names of other veterinarians/specialists that you have consulted about your pet's current problem:
Does your pet have other problems or are there other concerns either current or in the past that you feel may be related or that you may still have questions about?
Do you feel that your pet eats and drinks a normal amount?*

YesNo
Please describe the abnormality
Has your pet experienced any recent weight gain or loss?*

YesNo
Please describe the weight changes
Do you feel that your pet has a normal energy level and activity level for his/her age?*

YesNo
Please describe the energy/activity level:
For the following questions, please indicate yes or no for each question. If you answer yes for any question, please describe the conditions, severity, and frequency of the problem.
Has your pet experienced:
Skin infections or ear infections?*

NoYes
Please describe what treatments were prescribed and what was the response to treatment?
Musculoskeletal problems (pain, lameness, back problems)?*

NoYes
Please describe:
Neurologic problems such as weakness, paralysis, head tilt, seizures?*

NoYes
Please describe:
Vomiting or diarrhea - frequently,chronically, or recurring intermittently?*

NoYes
Please describe:
Respiratory problems such as nasal discharge, sneezing, excessive panting, difficulty breathing, or coughing?*

NoYes
Please describe:
Eye problems such conjunctivitis, dry eye, cataracts, or glaucoma?*

NoYes
Please describe:
Periodontal/gum disease, prior tooth extractions, surgical dental procedures?*

NoYes
Please describe:
Endocrine disease such as Cushing's, Addison's, hypothyroidism, or diabetes?*

NoYes
Please describe:
Cancerous growths?*

NoYes
Please describe:
Please describe your goals for this appointment:*
When the staff of Veterinary Wellness Center calls to schedule your pet's appointment, you will be asked to provide a valid credit card number that will be used to gaurantee the reserved time slot.

If you cancel your appointment with less than 24 hours notice or fail to arrive for your appointment, you will be charged for the full examination fee.

By signing below, you acknolwedge and consent to this cancellation/no-show policy.
Name*

First NameLast Name
Signature*
Should be Empty:

New Patient History

For the following questions, please indicate yes or no for each question. If you answer yes for any question, please describe the conditions, severity, and frequency of the problem.

Has your pet experienced: