Clone of Troy Veterinary Hospital Patient history form

Patient Exam History Form

Existing Clients and Patients
Today's Date and Time:
Primary Owner’s Name:*

First NameLast Name
Primary Owner’s Phone Number:*
Please enter a valid phone number.
Email*
example@example.com
Secondary Owner’s Name:

First NameLast Name
Secondary Owner’s Phone Number:*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's Name*
Species*
Species - Value
For fleas and ticks, I use*
FT - Value
When was my pet's last dose of their Flea and Tick Prevention?*
LD FT - Value
For Heartworm Prevention, I use?*
HW - Value
When was my pet's last dose of their Heartworm Prevention?*
LD HW - Value
Let's start with their mouth:
Do you have a concern for your pet's mouth or teeth?

YesNo
Mouth - Value
What are your concerns (check all that apply)?

Odor coming from mouthGums are red and irritatedTartar and/or discoloration on teethLumps and bumps around mouthConcerns about loose or broken teethHaving trouble chewing or drinkingOther
Mouth Concern - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Mouth Experience - Value
How long has this been going on?
Mouth Time - Value
Additional notes:
Mouth Notes - Value
And their eyes:
Do you have concern about your pet's eyes?

YesNo
Eyes - Value
I have concerns about (check all that apply):

Are red and irritatedHave a gunky dischargeAre "weepy"Are cloudy.Vision-my pet does not seem to see well.Frequently scratching or rubbing themOther
Eye Concerns - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Eye experience- Value
Which eye?

RightLeftBoth
Which Eye - Value
How long has this been going on?
Eye Time - Value
How much time outside?
Time Outside - Value
Any exposure to chemicals/irritants:
Chemicals/Irritants - Value
Have you observed:

SneezingCoughingNasal DischargeChange in appetiteVomiting or diarrheaItching or scratching on other parts of body
Observed - Value
Ears:
Do you have a concern for ears?

YesNo
Ears - Value
My pet's ears (check all that apply):

have some gunk and debris once in awhile.always seem to have some debris.sometimes have a yellow or brown discharge.seem red or swollen on the inside.seem swollen or irritated on the outside.seem itchy. S/he scratches them frequently.are of concern. My dog does not seem to hearing as well as s/he used to.
Ears have - Value
Which ear?

RightLeftBoth
Which Ear - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Ear experience- Value
How long has this been going on with the ears and has pet had previous issues?
Ear time - Value
Is there:

Head shakingHead tiltOdor from the ear(s)
Is there - Value
Have you observed:

SneezingCoughingNasal DischargeChange in appetiteVomiting or diarrheaItching or scratching on other parts of bodyChanges in dietChanges in swimming or bathing behavior
Ear observed- Value
Additional notes-are you using any cleaners or medications at this time?:
Ear notes - Value
Respiratory:
Do you have concerns about your pet's breathing?

YesNo
Breathing - Value
My pet (check all that apply)

seems to cough, sneeze, or gag more that s/he used to.seems to pant more.has changed his or her vocalizations.seems to get out of breath easily.seems to be more anxious, and I feel like his or her heart is beating faster at times.has intense coughing or gagginghas intense panting at timesOther
Breathing seems to - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Breathing experience- Value
How long has this been going on?
Breathing Time - Value
How often is your pet displaying problems (check all that apply)?

Cough or sneezes once or twice dailyCoughs or sneezes multiple times dailyMore frequent in the dayMore frequent at nightWorsens after exercise or movementFrequent pantingIncreased abdominal effort with breathingFainting episodes
Breathing how often - Value
Have you seen changes in activity level?

Less active than normalActivity level is the sameMore active than normalAppears lethargicAppears agitated
Activity Level - Value
Environment:

My dog goes to a groomer or doggie day careMy dog visits other households with pets or dog parksI foster pets and/or volunteer at a rescue or shelterThere are other pets in the household with respiratory symptoms.We have COVID-19 exposure in our household.
Environment- Value
Additional notes:
Breathing Notes - Value
Skin and Body:
Do you have concerns about your pet's skin?

YesNo
Skin - Value
My pet is:

scratchinglickingchewing/biting
Skin is - Value
My pet's coat and body (check all that apply)

is dull and not as soft as it used to be.is dry and my pet scratches frequently.seems to have an odor, and I see some crusty skin.has some hair loss.has open sores that do not heal.has some lumps and bumps.has patches of hardened or thickened skin.Has hot spotsHas a rashOther
Coat - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Skin experience- Value
How long has this been going on?
Skin Time - Value
Environmental changes:

My pet goes outside.My pet has been exposed to potential chemical irritants.There are other pets in the household with skin symptoms.My pet has had a change in diet.
Skin Environment- Value
What medications or treatments have you used?

regular bathsmedicated bathsOTC sprays/ointmentsOTC or natural flea/tick productsPrescription flea/tick productsPrescription oral medicationsFoods or supplements such as fish oil
Skin meds - Value
Mobility and movement:
Do you have concerns about your pet's walking and play?

YesNo
Move - Value
My pet (check all that apply)

seems awkward sometimes and limps once in awhile.is playing less than s/he used to, and having trouble moving.is slowing down and does not seem as interested in play.is stiff and has difficulty with stairs and climbing.seems to be painful sometimes when moving around.has an acute injury and is not walking on/toe touching one limbOther
Move my pet - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Move experience- Value
What is most affected?

Right front legLeft front legBoth front legsRight rear legLeft rear legBoth rear legsHips and entire back areaOverall mobility concernsOther
Move affect - Value
How long has this been going on?
Move Time - Value
Additional information:
GI system/weight/appetite
Do you have concerns about your pet's eating and elimination behavior?

YesNo
GI - Value
My pet (check all that apply)

Is gaining weight eating the same amount of food.has gained weight and is eating more.has gained weight but s/he is actually eating less.has lost weight but is still eating like s/he used to.has lost weight and is eating less.seems to be hungry all the time.seems to be thirsty all the time.is drinking more water than s/he used to.seems to have trouble eating his/her normal food.Does not seem to be that interested in food/refusingOther
GI my pet - Value
For primary nutrition, my pet eats (check all that apply):

a homemade diet.a raw food diet.a high quality commercial dry food.a high quality commercial wet food.a prescription diet.a commercial name brand dry food.a commercial name brand wet food.a store brand dry food.a store brand wet food.only people food.
GI Nutrition- Value
My pet (check all that apply)

is having trouble controlling his/her bladderis making messes in the houseseems to be urinating more frequently.seems to be defecating more frequently.has strong smelling urine.has unusually strong smelling stools.has frequent loose stools or diahrrea.seems to get constipated.seems to get nausea frequently.seems to vomit frequently.seems to have a sensitive stomach.frequently gets into stuff s/he should not eat.Other
GI my pet trouble - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Move experience - Value
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
Additional information and concerns:
Behavior:
Do you have concerns about your pet's behavior?

YesNo
Behave - Value
My pet (check all that apply)

continues to struggle with behavioral problems (please let us know what these are)is showing increased anxietyis showing increased aggressionsometimes seems confusedis not as responsive to us as s/he used to beis lethargic and sometimes acts depressed
Behave my pet - Value
Has your pet experienced this before?

It is a new problem.Yes and it is not as bad as it was before.Yes and it is about the same as it was before.Yes and it is worse that it was before.My pet has had frequent episodes of the same or similar problems.
Behave experience- Value
How long has this been going on?
Have there been any recent changes in your household environment that could be impacting your pet?
My primary concern today is:
Are there any other questions that you would like us to address at your visit?
Signature

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Patient Exam History Form

Let's start with their mouth:

And their eyes:

Ears:

Respiratory:

Skin and Body:

Mobility and movement:

GI system/weight/appetite

Behavior: