Patient History Form – NEW CONSULT

Pet Name: (First AND Last Name)

Briefly describe your pet's symptoms, and for how long have they been occurring?

Is your pet having vomiting? Check all that apply.

No vomiting Vomiting occurs immediately after eating or drinking Heaving/retching occur when vomiting Vomiting occurs without heaving/ retching Blood in vomit

If vomiting: for how long AND how many times per day?

Is your pet having any diarrhea? Check all that apply

If your pet is having diarrhea: for how long AND how many times per day?

Any coughing or sneezing?

Is your pet drinking more or less than usual?

Yes No

If yes, please describe:

(Time of day, amount estimate, etc)

Is your pet urinating more than usual?

Yes No

If yes, please describe:

(Time of day, increased volume versus increased frequency)

Is your pet eating more or less than usual?

Yes No

If yes, please describe:

If your pet is an intact female, when was her last heat cycle?

Have you noticed any new lumps or bumps on your pet? If yes please indicate where:

Has your pet traveled outside of Kentucky/Southern IN region?

Yes No

If yes, please indicate where and when:

Have you found any ticks on your pet in the past year?

Yes No

Is your pet on heartworm prevention?

No Yes

What food does your pet eat? (brand, canned and/or dry, how much, include any treats)

How long has your pet been on this diet?

If your pet is on a prescription diet has it helped?

Is your pet on any medications or supplements at this time?

Yes – Please list them below with the dosage and frequency if possible No

Medications / Supplements (if applicable)

Has your pet ever had any problems with anesthesia?

How many pets are in your household? (# cats, # dogs)

If you have other pets, are any of them ill? If yes please explain:

Additional Comments. Please let us know anything else that you feel that we should know about your pet.

Additional questions for cat owners:

Does your cat go outside?

Yes Yes, but only in a fenced in area No, indoor only

Has your cat been tested for Feline Leukemia Virus (FeLV) and Feline Immunodeficiency Virus (FIV)?

Not sure Yes No

If your cat has been tested for FeLV and FIV please check any results that were positive:

FeLV FIV

Veterinary Specialist Partners