Veterinary Specialist Partners
Patient History
Form
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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
Normal feces
Large amount of diarrhea a few times per day
Small amount of diarrhea very frequently
Pet strains when having a bowel movement
Blood in bowel movement
Mucous in bowel movement
Stools are black
Other
If your pet is having diarrhea: for how long AND how many times per day?
Any coughing or sneezing?
Dry Cough
Wet cough
Sneezing
Discharge around eyes and/or nose
Other
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
Submit
Should be Empty: