HVH Patient History Form
Please fill this out before your appointment. This information will be helpful for the doctors and technicians to have ahead of time.
Your Name
*
First Name
Last Name
Your pets name
*
When is your appointment?
*
-
Month
-
Day
Year
Date
What kind of appointment is your pet coming in for?
*
Wellness
Tech Visit
Sick Appointment
Recheck
Surgery
Does your pet (or anyone in your home) have any food allergies we need to be aware of? We often use peanut butter, cheese, tuna or other tasty snacks to help keep your pet calm and happy during their appointment. Please let us know if you would prefer we do not give them any snacks.
Any Coughing/Sneezing/Vomiting/Diarrhea
*
Yes
No
Please elaborate:
Is your pet Eating/Drinking/Urinating/Defecating normally?
*
Yes
No
Please elaborate:
What kind of diet do you feed your pet? What brand specifically?
Is your pet on any medication?
*
Yes
No
Please write the name of the medication, the dosage, and how frequently you are giving it.
Is your pet on flea/tick medication?
Yes
No
What is the name of the flea/tick product?
Is your pet on heartworm prevention?
Yes
No
What is the name of the heartworm prevention?
Do you give this heartworm prevention year round?
Yes
No
Is your pet indoor/outdoor?
Indoor only
Outdoor only
Both
Are there other pets in the household?
Yes
No
Are they on flea/tick medication?
Yes
No
Do you have any questions/concerns today? If yes please describe in detail to the veterinarian can address them.
Your pet will be seeing a technician for their treatments. Please document below if there are any addition services you would like your pet to have during their appointment.
Nail Trim
Anal Gland Expression
4DX Bloodwork
Other
Submit
Should be Empty: