Veterinary Patient History Form

Pet's Name

First NameLast Name

Who is your pet seeing today?

Your Name

First NameLast Name

It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.

Where can we call you at while your pet is here?

Format: (000) 000-0000.

Have you or your pet traveled outside of Washington state in the last 14 days?

Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?

Have you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?

Reason for your pet's visit today?

This issue began on:

Date

This issue is:

Has your pet had any:

Color

Texture

Frequency

Consistancy

Duration

Blood present?

Is the cough productive?

Is there mucous present?

Color

Has your pet had any:

Please Describe Changes

Location of Lumps/Bumps

When Did You Notice Them?

Any Discharge or Odor from Bumps?

My pet's appetite is:

If increased or decreased, please provide more information:

My pet's thirst level is:

If increased or decreased, please provide more information:

My pet's activity level is:

If increased or decreased, please provide more information:

My pet's urination is:

Color

Amount

Frequency

Duration of Abnormal Urination

My pet eats

Brand of Pet Food

If prescription diet, what formulation?

How Often Is Your Pet Fed?

How Much Is Your Pet Fed?

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)

Has your pet's diet changed in the last 6 months?

Is it possible for your pet to have:

Please tell us more:

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:

When Was Your Pet's Last Dose of Heartworm Preventative?

Date Given (Please type N/A if not on a preventative)

What Kind of Heartworm Preventative Do You Use?

Name of medication - put unknown if not sure

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use?

Name of medication - put unknown if not sure

Is Your Pet:

Are There Other Pet's In The Home

Please tell us about the other pet's in your home

Does Your Pet:

Is Your Pet Current On Vaccinations?

My pet's vaccines were administered last by:

Other

Does Your Pet Have A Microchip?

Has Your Pet Bitten Anyone In the Last 15 Days?

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?

If yes, please tell us more. If no, please note N/A

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

Please upload if available.

Is There Anything Else You Would Like To Discuss Today?

I understand I should remain in my vehicle at all times while on Veterinary Clinic grounds. This is for your safety and the safety of our clients and patients

Initial

I understand that access to the Clinic building is limited to employees only at this time.

Initial

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.

Initial

Signature

Patient History Form

Appointment Procedures