Patient History Form

1

Your Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Pet's Name* This field is required.

4

Cat or Dog* This field is required.

Cat

Dog

5

Does your cat go outdoors or stay indoors?* This field is required.

Exclusively indoor

Exclusively outdoor

Both Indoor and outdoor

6

Do you regularly apply flea control?* This field is required.

YESNO

7

Please enter the brand of flea control, if known.

8

Which vaccines does your cat usually receive?* This field is required.Check all that apply.

Rabies

FeLV (Feline Leukemia)

FVRCP (Feline Viral Rhinotrachetis, Calicivirus, Panleukopenia/Distemper)

My cat does not usually receive vaccines.

My cat is regularly vaccinated, but I'm not sure which vaccines are given.

Other

9

Which vaccines does your dog usually receive?* This field is required.Check all that apply

Rabies

DA2PP (Distemper, Adenovirus-2, Parainfluenza, Parvo)

Leptospirosis

Bordetella (kennel cough)

Canine Influenza

My dog is regularly vaccinated, but I'm not sure which vaccines are given.

My dog does not receive vaccinations.

Other

10

Will your dog need any vaccines administered during your visit?* This field is required.

Yes

No

I would like to discuss vaccines with the doctor before I decide.

11

Will your cat need any vaccines administered during your visit?* This field is required.

Yes

No

I would like to discuss vaccines with the doctor before I decide.

12

Which vaccines does your cat need during this visit?* This field is required.Check all that apply

Rabies

FeLV

FVRCP

Other

14

Does your dog receive a heartworm preventative?* This field is required.

YESNO

15

Which heartworm preventative does your dog receive?* This field is required.Interceptor Plus, Heartgard, Trifexis, Revolution, Sentinel, etc.

16

Is your pet currently receiving any medications, herbs or supplements?* This field is required.

YESNO

17

Please list all medication, herbs or supplements your pet is currently receiving.* This field is required.

18

Has your pet been previously diagnosed with any specific illness, condition, or had any surgical procedure (other than spay or neutering)?* This field is required.

YESNO

19

Please list/describe any previously diagnosed illnesses, chronic or terminal conditions and past surgeries.* This field is required.

20

Does your pet have any current injuries or wounds?* This field is required.

YESNO

21

Please describe any injuries or wounds and what part of the body they are located.* This field is required.

22

Please describe what foods and treats your pet is currently eating.* This field is required.

23

Has your pet's diet remained unchanged for the past 60 days?* This field is required.

YESNO

24

Please describe what changes you've made to their diet.* This field is required.

25

Does your pets appetite appear normal?* This field is required.

YESNO

26

Please describe what you've observed about your pet's appetite.* This field is required.

27

Does your pet's weight appear normal?* This field is required.

YESNO

28

Please describe what you've observed about your pet's weight.* This field is required.Is s/he overweight or underweight? Has s/he been losing weight or gaining weight recently? Describe how s/he appears to you.

29

Has your pet been vomiting recently?* This field is required.

YESNO

30

Please describe the vomiting* This field is required.How long has this been going on? How many times has s/he vomited, or if chronic, how frequently does vomiting occur? Does the vomiting seem to be associated with eating, or not? Can s/he keep water down?

31

Does your pet's stool appear normal?* This field is required.Firm, well formed, not too wet or dry, etc. **For annual exams, please have a fresh stool sample available whether it appears normal or not.**

YESNO

32

Please describe your pet's stool.* This field is required.Diarrhea? Pudding-like or watery? Contains blood or mucus? How often and how long as it been going on? Dry and hard or straining to defecate? Several days since last bowel movement? **If your pet's stool is abnormal, please have a fresh stool sample available if possible at time of visit.**

33

Does your pet's water intake seem normal?* This field is required.

YESNO

34

Please describe your pet's drinking habits.* This field is required.Are they drinking more or less frequently? Are they drinking more volume or less volume? Do they seem thirsty all the time? Do they never seem thirsty? Other observations?

35

Do your pet's urination habits seem normal?* This field is required.

YESNO

36

Describe your pet's urination habits.* This field is required.Are they urinating a larger/smaller volume? Do they need to go more/less often? Are they having accidents in the home? Do they strain to go or is there any observable pain? Other observations?

37

Please describe your cat's current use of their litter box.* This field is required.

Eliminates inside a litter box all the time.

Eliminates outside the litter box (indoors) occasionally.

Eliminates outside the litter box (indoors) frequently or all of the time.

Eliminates outdoors and does not use a litter box.

Other

38

How long has your cat been eliminating outside the litter box?* This field is required.

Just started today

The last few days.

The last few weeks.

The last few months or longer

Other

39

Does your pet's skin, coat or fur seem to be normal?* This field is required.

YESNO

40

Describe what seems abnormal about your pet's skin, coat and/or fur.* This field is required. Are there open sores or wounds? An odor? Are there red areas or unusual markings on the skin?

41

Does your pet frequently scratch or chew a particular area (or areas) of their body?* This field is required.

YESNO

42

Please describe what area of your pet's body seems to be most itchy.* This field is required.Entire body. Around ears, face, sides, etc.

43

Does your cat seem to be grooming normally?* This field is required.

YESNO

44

Describe your cat's grooming habits.* This field is required.Doesn't seem to groom anymore? Is there a part of the body s/he grooms over and over frequently? What part of the body? Other observations?

45

Do you have any concerns about your pet's activity level?* This field is required.

YESNO

46

Describe what you have observed about your pet's activity level.* This field is required.Hyperactive? Restless? Lethargic or more sedentary? Sleeping more or less than usual? Pacing?

47

Do you have any mobility concerns about your pet?* This field is required.

YESNO

48

Describe the mobility concerns you have about your pet.* This field is required.Difficulty standing? Limping? Moving stiffly? Moves with pain? Only stands with assistance? Other observations?

49

Do you have any behavior concerns about your pet?* This field is required.

YESNO

50

Describe the behavior that concerns you.* This field is required.Aggressive with other pets or with people? Inappropriate urination or defecation? Spraying? (cats). Damages furniture? Seems stressed or anxious? Other observations?

51

Do you have any specific health concerns not previously described that you would like the doctor to address?* This field is required.

YESNO

52

Please describe the other health concerns you have about your pet at this time.* This field is required.

53

What are your goals for your home visit with the doctor?* This field is required.

54

Do you have another pet history to add?* This field is required.If you select "Yes" you will be taken back to the beginning of this form to enter another pet history.

YESNO

55

Please verify that you are human* This field is required.