Patient History

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Patient History

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104Questions

1
Owner's Name
First Name
Last Name
2
Pet's Name
3
Chief complaint or reason for visit?
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.)
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.)
6
Is your pet around any other animals? If so, what other pets?
7
Describe your pet’s eating habits:
Normal
Decreased
Increased
8
Please explain if increased or decreased:
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.
10
What kind of food does your pet eat?Brand and flavor
11
What kind of snacks or treats does your pet eat?
12
How often is your pet fed & how much?
13
Does your pet get table food? If so, what & how often?
14
Describe your pet’s drinking habits
Normal
Decreased
Increased
15
Please explain if increased or decreased:
16
Do they share a water bowl with other pets?
YESNO
17
How often do you change the water in one day?
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.
19
Is your pet on any medications (including heartworm/flea/tick prevention)?
YESNO
20
Heartworm Medication Brand?
21
Flea/Tick Prevention Brand?
22
Over the counter medications?Please include dosage and frequency.
23
Prescription medications?Please include dosage and frequency.
24
When was the last dose given?
25
Does your pet have any medical conditions (Previous or Current)?
26
Has your pet been experiencing any diarrhea?
YESNO
27
When did it start?
28
How often? Frequency?
29
Is there any blood or mucous in the stool? If so, was the blood dark red or bright red?
30
Describe the consistency (cow patty, soft served ice cream, liquid, etc.):
31
What is the volume of the stool?
32
Could they have eaten something inappropriate? If so, what & when?
33
Have you administered any medications? If so, what & when?
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.
35
Has your pet been experiencing any vomiting?
YESNO
36
When did it start?
37
How soon before or after eating does the vomiting occur?
38
Is the food digested or undigested?
Digested
Undigested
39
Are there any foreign objects in the vomit? If so, what?
40
What is the consistency of the vomit? Ex: food, water, bile, color
41
How frequently are they vomiting?
42
Could they have eaten something inappropriate? If so, what & when?
43
Have you administered any medications? If so, what & when?
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.
45
Is your pet experiencing any coughing?
YESNO
46
When did it start?
47
How often do they cough?
48
Describe the cough.Dry/hacking, productive, high pitch wheeze, etc.
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
50
Does the cough seem to happen more at a certain times of the day or after a certain activity?
51
Is your pet experiencing any sneezing?
YESNO
52
When did it start?
53
Is it constant or intermittent?
54
Is there any nasal discharge? If so, clear/mucous/greenish yellow/bloody:
55
Does your pet spend any time outside unattended?
YESNO
56
Is your pet urinating normally?
YESNO
57
Has the urine production increased or decreased?
Increased
Decreased
58
When did this start?
59
Is this change daily?
YESNO
60
When was the last time they urinated?
61
Is there any straining to urinate?
YESNO
62
Do they ever posture & not produce any urine?
YESNO
63
Is the odor stronger than normal?
YESNO
64
What is the color of the urine?(Clear, yellow, bloody, etc.)
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.
66
What is your pet’s exercise tolerance like?
Normal/Stable
Progressed
Regressed
67
Please explain the change:
68
When did you first notice the change?
69
Describe your pet’s general attitude:
70
Are you happy with their attitude?
YESNO
71
Have you seen any behavioral changes?
YESNO
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
73
Please describe signs of aggression in detail:
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.
75
Have you noticed any lumps/bumps on your pet?Both new or pre-existing.
YESNO
76
Are they new?
YESNO
77
Have they been looked at before?
YESNO
78
Do they bother the pet?
YESNO
79
Have they changed in shape or size?
80
Have you noticed any limping or favoring of limbs?
YESNO
81
Which leg?
Front Right
Front Left
Back Right
Back Left
82
Is it constant or intermittent?
83
Are they weight bearing or holding completely up?
84
Has there been an injury? If so, when did the injury occur & describe:
85
Have you noticed any issues with your pet’s ears?
YESNO
86
Which ear is affected?
Right
Left
Both
87
When did it start?
88
Is your pet scratching or shaking their head? Is it keeping you or your pet up at night?
89
Does your pet have a history of ear infections? If so, how often do they occur? Does it seem to be seasonal?
90
Have you given or applied any medication? If so what & when?
91
Have you noticed any issues with your pet’s skin?
YESNO
92
When did it start?
93
Is your pet licking, biting, scratching themselves? Is it keeping you or your pet up at night?
94
Does your pet have a history of skin infections? If so, how often do they occur? Do they seem to be seasonal?
95
Have you given or applied any medications? Have you bathed with any shampoo or conditioner? If so, what & when?
96
Have you noticed any changes with your pet’s eyes?
YESNO
97
Which eye is affected?
Right
Left
Both
98
Is your pet rubbing or squinting their eyes?
99
Has there been an injury to the eye? If so, when did the injury occur & describe the nature of the injury?
100
Is there any discharge coming from the eye(s)?Please describe. (clear, yellow, green)
101
Any special instructions or questions?
Huge
Large
Normal
Small
Ok
Ok
102
Printed name of Responsible Party:
103
Signature
Clear
104
Phone NumberPlease provide the phone number you will be available at during the appointment time.
Area Code
Phone Number
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