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Patient History
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104
Questions
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1
Owner's Name
First Name
Last Name
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2
Pet's Name
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3
Chief complaint or reason for visit?
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4
Is your pet inside, outside or both? If pet goes outside what is the environment like?
(Ex: leash walked, fenced in yard, free roam, tie out/runner, dog lot, etc.)
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5
Does your pet travel outside of your home? If so, how often & where?
(Hiking, camping, dog parks, out of the state, pet stores/stores in general, grooming, etc.)
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6
Is your pet around any other animals? If so, what other pets?
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7
Describe your pet’s eating habits:
Normal
Decreased
Increased
Other
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8
Please explain if increased or decreased:
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9
Has anything changed at the time of the food intake?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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10
What kind of food does your pet eat?
Brand and flavor
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11
What kind of snacks or treats does your pet eat?
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12
How often is your pet fed & how much?
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13
Does your pet get table food? If so, what & how often?
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14
Describe your pet’s drinking habits
Normal
Decreased
Increased
Other
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15
Please explain if increased or decreased:
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16
Do they share a water bowl with other pets?
YES
NO
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17
How often do you change the water in one day?
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18
Has anything changed at the time of the water intake?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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19
Is your pet on any medications (including heartworm/flea/tick prevention)?
YES
NO
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20
Heartworm Medication Brand?
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21
Flea/Tick Prevention Brand?
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22
Over the counter medications?
Please include dosage and frequency.
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23
Prescription medications?
Please include dosage and frequency.
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24
When was the last dose given?
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25
Does your pet have any medical conditions (Previous or Current)?
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26
Has your pet been experiencing any diarrhea?
YES
NO
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27
When did it start?
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28
How often? Frequency?
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29
Is there any blood or mucous in the stool? If so, was the blood dark red or bright red?
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30
Describe the consistency (cow patty, soft served ice cream, liquid, etc.):
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31
What is the volume of the stool?
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32
Could they have eaten something inappropriate? If so, what & when?
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33
Have you administered any medications? If so, what & when?
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34
Has there been any environmental changes at the time of when the diarrhea was noticed?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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35
Has your pet been experiencing any vomiting?
YES
NO
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36
When did it start?
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37
How soon before or after eating does the vomiting occur?
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38
Is the food digested or undigested?
Digested
Undigested
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39
Are there any foreign objects in the vomit? If so, what?
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40
What is the consistency of the vomit?
Ex: food, water, bile, color
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41
How frequently are they vomiting?
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42
Could they have eaten something inappropriate? If so, what & when?
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43
Have you administered any medications? If so, what & when?
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44
Has there been any environmental changes at the time of when the vomiting was noticed?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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45
Is your pet experiencing any coughing?
YES
NO
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46
When did it start?
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47
How often do they cough?
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48
Describe the cough.
Dry/hacking, productive, high pitch wheeze, etc.
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49
Did your pet lose consciousness before, during, or after the cough? If so, for how long? Did you noticed your pet’s mucous membrane color (color of the gums)? White/pink/red/purple
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50
Does the cough seem to happen more at a certain times of the day or after a certain activity?
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51
Is your pet experiencing any sneezing?
YES
NO
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52
When did it start?
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53
Is it constant or intermittent?
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54
Is there any nasal discharge? If so, clear/mucous/greenish yellow/bloody:
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55
Does your pet spend any time outside unattended?
YES
NO
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56
Is your pet urinating normally?
YES
NO
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57
Has the urine production increased or decreased?
Increased
Decreased
Other
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58
When did this start?
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59
Is this change daily?
YES
NO
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60
When was the last time they urinated?
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61
Is there any straining to urinate?
YES
NO
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62
Do they ever posture & not produce any urine?
YES
NO
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63
Is the odor stronger than normal?
YES
NO
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64
What is the color of the urine?
(Clear, yellow, bloody, etc.)
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65
Has anything changed at the time of when urination habits changed?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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66
What is your pet’s exercise tolerance like?
Normal/Stable
Progressed
Regressed
Other
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67
Please explain the change:
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68
When did you first notice the change?
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69
Describe your pet’s general attitude:
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70
Are you happy with their attitude?
YES
NO
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71
Have you seen any behavioral changes?
YES
NO
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72
Please select behavioral problem(s) your pet is exhibiting:
Select all that apply.
Eliminating in the house
No longer sleeping through the night/Changes in sleep patterns
Need to eliminate more often
No longer coming when called
Seems depressed
More active
Signs of aggression
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73
Please describe signs of aggression in detail:
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74
Has anything changed at the time of the behavior change?
Diet, weather, visitor at home, new baby, new pet, new home, vacation, prescriptions, over the counter supplements, etc.
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75
Have you noticed any lumps/bumps on your pet?
Both new or pre-existing.
YES
NO
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76
Are they new?
YES
NO
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77
Have they been looked at before?
YES
NO
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78
Do they bother the pet?
YES
NO
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79
Have they changed in shape or size?
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80
Have you noticed any limping or favoring of limbs?
YES
NO
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81
Which leg?
Front Right
Front Left
Back Right
Back Left
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82
Is it constant or intermittent?
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83
Are they weight bearing or holding completely up?
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84
Has there been an injury? If so, when did the injury occur & describe:
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85
Have you noticed any issues with your pet’s ears?
YES
NO
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86
Which ear is affected?
Right
Left
Both
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87
When did it start?
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88
Is your pet scratching or shaking their head? Is it keeping you or your pet up at night?
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89
Does your pet have a history of ear infections? If so, how often do they occur? Does it seem to be seasonal?
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90
Have you given or applied any medication? If so what & when?
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91
Have you noticed any issues with your pet’s skin?
YES
NO
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92
When did it start?
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93
Is your pet licking, biting, scratching themselves? Is it keeping you or your pet up at night?
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94
Does your pet have a history of skin infections? If so, how often do they occur? Do they seem to be seasonal?
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95
Have you given or applied any medications? Have you bathed with any shampoo or conditioner? If so, what & when?
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96
Have you noticed any changes with your pet’s eyes?
YES
NO
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97
Which eye is affected?
Right
Left
Both
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98
Is your pet rubbing or squinting their eyes?
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99
Has there been an injury to the eye? If so, when did the injury occur & describe the nature of the injury?
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100
Is there any discharge coming from the eye(s)?
Please describe. (clear, yellow, green)
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101
Any special instructions or questions?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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102
Printed name of Responsible Party:
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103
Signature
Clear
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104
Phone Number
Please provide the phone number you will be available at during the appointment time.
Area Code
Phone Number
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