Patient Health History Form

"*" indicates required fields

An important part of the medical evaluation is an accurate history. Please take a few moments to complete this questionnaire. Please fill out 1 form for each pet that will be having an exam today. Do your best to answer all of the questions you can. The more information that we have, the better care we can provide for your pet. Additional information may be requested during consultation by the veterinarian.

Client Information

Name*

First Last

Date*

MM slash DD slash YYYY

Pet Information

Pet Name*

Species*

Canine

Feline

Other

Sex*

Female

Male

Spayed/Neutered*

Yes

Unsure

Age*

Date of Birth (if known)*

Breed*

Color/Markings*

Microchipped?*

Yes

Unsure

What is the primary reason(s) you are seeking veterinary medical attention for your pet today

Microchip #

Vaccination History

Has your pet ever been vaccinated?*

Yes

Unsure

If yes, please provide a record of vaccination history here or attach it below.

Date of last Rabies Vaccination

Has your pet ever suffered a vaccine reaction in the past?*

Yes

Unsure

Environment

My pet is:*

Exclusively indoor

Exclusively outdoor

Both indoor and outdoor

Do you take your pet camping/hiking/fishing/boating/groomers/dog parks?*

Yes

Are there other pets in the house?*

Yes

If yes, please list species and age.

Has your pet previously traveled?*

Yes

Please describe.

Are there young children present in the house?*

Yes

Flea/Tick/Heartworm/Deworming

Is your pet on flea/tick preventive?*

Yes

If yes, what product?

Has your pet ever been dewormed?*

Yes

Unsure

If yes, what product?

Is your pet on a heartworm preventive?*

Yes

If yes, what product?

Has your pet ever had a heartworm test?*

Yes

Unsure

If yes, was the test negative?

For cats, has your cat ever had a leukemia/FIV test?*

Yes

Unsure

If yes, was it negative?

Grooming

When is the last time your pet was groomed?*

What grooming facility do you frequent (if any)?*

How often does your pet get a bath?*

Dental

Do you brush your pet’s teeth?*

Yes

If yes, when?

Do you use dental products?*

Yes

If yes, what brand of product(s)?

Does your pet:*

Suffer from bad breath

Drop food/drool

Experience difficulty eating

Chew on one side

None of the above

Please select all that apply.

Food

Your pet’s diet is predominately:*

Dry food

Wet/canned food

Raw food

Freeze dried food

Human food

Combination

What brand(s) of food do they eat?*

What supplements/treats do you give your pet?*

Does your pet get table scraps?*

Yes

How often does your pet get treats?*

Once a day

Multiple times per day

Weekly

Monthly

Recently has your pet’s appetite:*

Decreased

Increased

Stayed the same

Not sure

What about your pet’s water consumption?*

Decreased

Increased

Stayed the same

Not sure

When did your pet last eat?*

When they last ate, was it a normal amount?*

Yes

Unsure

Is there anything else we should know about your pet’s diet?*

Medications

Is your pet on any medications?*

Yes

if yes please list them and the last time your pet has received a dose.

Does your pet have any known allergies?*

Yes

Unsure

If yes, please please describe.

Has your pet ever experienced an adverse event or allergic reaction to medications and/or sedation/anesthesia?*

Yes

Unsure

If yes, please elaborate.

Lab Work

Has your pet ever had lab work?*

Yes

Unsure

If yes, please list the last date(s) of their bloodwork.

Has your pet ever had radiographs/x-rays?*

Yes

Unsure

If yes, what were they for and what were the results?

Has your pet ever had a fecal analysis?*

Yes

Unsure

If yes, when and what were the results?

Has your pet ever had a urinalysis?*

Yes

Unsure

If yes, when and what were the results?

Last Veterinary Visit

Is this your pets first vet visit?*

Yes

Unsure

If no, have they been here or to another vet hospital before?

Please write the hospital/date/doctor/diagnosis and attach medical records

Please check any signs/symptoms you have noticed recently about your pet.**

Bad Breath

Lack of appetite

Behavioral Problems

Limping/stiffness

Bleeding gums

Loss of balance

Breathing problems

Lumps/bumps

Coughing

Scooting

Diarrhea

Scratching

Ear Issues

Seems depressed

Eye Discharge/Swelling

Seizures

Eyes bulging/bloodshot

Shaking head

Fainting

Spraying house/yard

Fleas/ticks

Sneezing

Gagging

Vomiting

Hair loss

Weakness

Increased thirst

Weight decrease

Weight Increase

Other

Please select all that apply.

If other, please elaborate.

Has your pet ever had a history of injury, trauma, or been diagnosed with a medical illness?*

Yes

Unsure

If yes, please describe in detail.

Temperament

Describe your pet’s normal temperament.*

Does your pet show any reluctance to getting in the carrier or car?

Yes

How and where does your pet travel in the car?*

carrier/seatbelt/loose/box/etc

How would you describe your pet’s behavior during travel?

Eager & excited

Subdued

More quiet than usual

More vocal than usual

Does your pet do any of the following during travel?

Pant

Tremble

Pace

Hide

Drool

Vomit

Poop

Pee

Do you use any anxiety supplements/medications for traveling?*

Yes

If yes, please elaborate.

My pet prefers:*

Female veterinary staff

Male veterinary staff

No preference/unknown

Has your pet ever exhibited aggressive tendencies towards other pets?*

Yes

Unsure

Has your pet ever exhibited aggressive tendencies towards people?*

Yes

Unsure

How would you describe your pet around other animals and people?*

Does your pet have any sensitive areas that s/he does not like to have touched by you or others?*

Are there any procedures that you have been told seem difficult to perform on your pet? (nail trims, weight, temperature, ear exam, blood draw, etc.) and elaborate on how your pet reacted.*

What is your pet’s favorite toy(s); if any?*

Check any situations below that your pet has shown avoidance or dislike of in the past.*

Entering the veterinary hospital

Unfamiliar people and/or animals

Getting onto the scale

Going into the exam room

Being put up on an exam table

Being picked up or carried

Being removed from a carrier

Having a rectal temperature taken

Ear exam/cleaning

Placement of the stethoscope on the chest