Sandwich Veterinary Hospital Pre-exam History
Thank you for taking the time to fill out this brief recent history form so we can better evaluate your pet during your appointment!
Owner's Name
*
First Name
Last Name
Pet's Name
*
Phone Number
*
-
Area Code
Phone Number
Can we text message you at this number?
Yes
Email
example@example.com
Have we seen you/your pet before?
Yes! I am a current client and you've seen my pet before
I am a current client but I have a new pet in my family!
I'm a new client!
Welcome! Who was your previous vet? We will contact them for your pet's medical history so we can provide the best care for your pet!
Have you or anyone in your household tested positive for COVID-19 in the last 2 weeks or are currently experiencing respiratory symptoms? (This allows our staff to properly protect you and ourselves!)
*
Yes
No
General Health Questions
How is your pet's appetite?
Normal
Increased
Decreased
Absent (Not eating)
How is your pet's water consumption (drinking)?
Normal
Increased
Decreased
Absent (Not drinking)
What brand of food(s) does your pet currently eat, please specify if these are kibble (dry) or canned (wet)?
Is your pet:
Free fed (food out all the time)
Meal fed (food provided at specific times)
How much food does your pet eat per day?
Is your pet currently on flea/tick preventative?
Yes
No
What brand of flea/tick preventative?
Date of last flea/tick preventive (an approximate date is fine!)
/
Month
/
Day
Year
Date
Is your pet currently on heartworm preventative?
Yes
No
What brand of heartworm preventative?
Date of last heartworm preventive
/
Month
/
Day
Year
Date
Is your pet currently on any medications, supplements, or nutraceuticals? If yes, please list below:
Medical Questions
Please answer the following questions below regarding any symptoms or concerns about your pet you'd like to discuss with the doctor.
Is your pet URINATING normally?
Yes
No
Please describe the abnormal urination
0/500
Is your pet DEFECATING normally?
Yes
No
Please describe the abnormal defecation including the last time your pet had a bowel movement and the consistency of the stool if applicable.
0/500
Is your pet's ATTITUDE/BEHAVIOR normal?
Yes
No
Please describe the abnormal attitude/behavior
0/500
Any VOMITING?
Yes
No
Please describe the vomiting including how long this has been going on, how many times your pet has vomited, when the vomiting occurs (i.e. in association with eating, first thing AM, after drinking), and what the vomit looks like
0/500
Any COUGHING/SNEEZING?
Yes
No
Please describe the coughing/sneezing including how often and if there is any discharge
0/500
Any LIMPING or DIFFICULTY MOVING AROUND?
Yes
No
Please describe the limping or difficulty moving around, if an injury was observed please describe when and what happened
0/500
Any ITCHING?
Yes
No
On a scale of 1-10 how itchy would you say your pet is?
1
2
3
4
5
6
7
8
9
10
Least itchy
Most itchy
1 is Least itchy, 10 is Most itchy
How long has the itching been going on?
0/500
Where is your pet itching (one particular spot vs all over)?
0/500
Has your pet ever been diagnosed with or suspected of having allergies? If yes, what have you treated this with in the past and did it help?
0/500
Is there anything else you would like us to know?
Submit
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