Patient History Form

Appointment:
Please arrive 10mins before your appointment time If your pet is scheduled for a routine annual exam, we recommend yearly blood work and viral screening, fecals checked twice yearly and vaccines due updated. We will provide an estimate of what we have in our records that is needed for your pet for you to review when we come to your car.

Drop off Appointment:
Please provide best contact number. Our front desk team will be contacting you to provide you with additional information.

Additional Information:
Please down load our app before your appointment to start earning Loyalty Paws! If you are interested ion signing up pet on a wellness plan please let us know so we can provide you with information. We are your Compassionate Partner for the BEST health of your pet!!

Your Name

First Last

Pet's Name

Phone

Date

Pet Information

Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.

For how long has your pet been experiencing the problem described above?

Has your pet had any coughing?

Yes
No

If yes, for how long? Please provide more details.

Has your pet had any sneezing?

Yes
No

If yes, for how long? Please provide more details.

Does your pet have any nasal discharge?

Yes
No

If yes, for how long? Please provide more details.

Has your pet been vomiting?

Yes
No

If yes, for how long? Please provide more details.

Has your pet had diarrhea?

Yes
No

If yes, for how long? Please provide more details.

Does your pet’s stool look normal in color?

Yes
No

If no, is it black or bloody?

Yes
No

Has your pet been drinking more?

Yes
No

Has your pet been urinating more?

Yes
No

Have you seen your pet's urine?

Yes
No

If yes, what was the color and amount?

Has your pet's appetite changed?

Yes
No

If yes, for how long? Please provide more details.

When was the last time you saw a bowel movement and what did it look like?

What is the name of the food you feed your pet? Is it canned, dry or both? Specifically, what is the volume of food and treats you are feeding per day?

What brand of food do you feed your pet?

How often do you feed your pet?

How much do you feed him or her?

Is your pet lethargic (not active)?

Yes
No

If yes, for how long? Please provide more details.

Is your pet here because it is limping?

Yes
No

If yes, can you describe what happened or when the lameness started and on which leg?

Please list all medications and supplements/vitamins (name, strength, and amount) your pet is on and when they were last given:

Has your pet cried out or acting in pain?

Yes
No

If yes, what was your pet doing when this occurred?

Does your pet have a problem with one or both of its eyes?

Yes
No

If yes, for how long? Please provide more details.

Does your pet have a problem with one or both of its ears?

Yes
No

If yes, for how long? Please provide more details.

Do you have a concern with your pet’s teeth?

Yes
No

If yes, for how long? Please provide more details.

Would you like your pet’s nails trimmed while here?

Yes
No

Please note this is at an additional cost. Please ask a member of our team if you have questions.

Comment if any concerns with the nails.

Would you like your pet’s anal glands emptied while here?

Yes
No

Please note this is at an additional cost. Please ask a member of our team if you have questions.

Comment if any concerns with them. Any scooting or licking?

Are there any new lumps or bumps you have found?

Yes
No

If yes, for when did you notice the lump(s)? Please provide more details.

Any additional information that you feel would be helpful in treating your pet. We will do our best to have your pet seen and communicate a plan as quickly as possible

Monday	7:30 am – 6:00 pm
Tuesday	7:30 am – 7:00 pm
Wednesday	7:30 am – 6:00 pm
Thursday	7:30 am – 7:00 pm
Friday	7:30 am – 6:00 pm
Saturday	8:00 am – 2:00 pm
Sunday	Closed

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