Medical History
Thank you for filling out this form and helping our staff prepare for your visit. 15 questions.
Your Pet's Name
*
Your Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date of your appointment
*
-
Month
-
Day
Year
Date
Address (if changed since last visit)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
So that we may assess disease risk and customize our health recommendations for your pet, please indicate any of the following that apply.
*
My Dog goes to dog parks or doggie day care
My Dog goes to a boarding kennel
My Dog goes to a groomer
My Dog goes to training classes or dog sporting events
My Dog goes camping and/or hiking
My Dog doesn't interact with other dogs outside of my family
My Cat is strictly indoors and NEVER slips outside
My Cat goes outside on a porch or deck and never touches the grass
My Cat is indoor/outdoor or escapes to the outdoors
Please list all medications, parasite preventives, supplements, and vitamins your pet is currently taking. Please include Name, dosage, and frequency:
*
Write NONE if your pet is not currently on medications, supplements, or vitamins.
Please list any medications you will need refilled at your appointment or write none?
*
Write NONE if your pet does not need any refills.
Please list all of your pet's known allergies to Medications, vaccines or food.
*
Write NONE if your pet has no allergens.
Please list the type, brand, and amount of food your pet receives. Please include treats.
*
Is your pet on a grain-free or raw diet? Select all that apply.
Raw
Grain-Free
No, my pet is not on a raw or grain-free diet
Unknown
Please check all symptoms that your pet is currently experiencing. Explain details in the space below.
*
Vomiting (describe frequency below)
Diarrhea (describe frequency below)
Constipation
Sneezing
Coughing
Decreased mobility
Lameness or limping
Lethargy
Appetite changes (please describe below)
Concerns about pet's weight (increase or decrease)
Increased drinking/water intake
Increased urination amount or frequency
Urinary or stool accidents in the house
Eye problems
Skin and/or ear problems
Mouth or tooth problem
Behavioral changes (please describe below)
None, my pet seems healthy and I have no concerns
Please provide details about your concerns. Please list the date concerns began (duration, frequency, severity, etc.). List any additional information you feel may be helpful to the doctor.
Would you like information about our Wellness Plans for puppies/kittens, adult pets, and/or senior pets?
Yes
No
My pet is already on a Wellness Plan
Do you have any upcoming travel plans with your pet?
Yes, travel within the United States
Yes, international travel
No
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