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Patient History Questionnaire - Annual/Vaccine
Client Info
Name
First
Last
Email
Phone you can be reached at today
Alternate Contact Phone
Patient Info
Patients Name
If you have any concerns for your pet please list and describe below:
What does your pet do for exercise (walks, playing with toys, swimming, etc)?
My pet’s energy level seems to be
Increased
Decreased
Unchanged
Has your pet’s traveled out of the area with you since his/her last visit with us, or do you plan to travel with him/her before we are likely to see him/her again?
No
Yes
Where did/will your pet be travelling?
Does your pet stay at a boarding kennel, or do you think that he/she is likely to do so in the next year?
No
Yes
Please provide details
Does your pet live with any other animals?
No
Yes
What other animals does your pet live with?
How much time does your pet spend outdoors?
Diet
What do you feed your pet? Please list the type of diet (kibble, canned, etc), brand name, amount fed and number of meals fed in a day:
What is your pet given as treats (including table food)?
Concerns
Do you have any concerns about your pet’s urination habits (straining to urinate, inappropriate urination, etc)?
No
Yes
Please describe
Do you have any concerns about your pet’s eating or drinking habits (vomiting, change in appetite or drinking, etc)?
No
Yes
Please describe
Does your pet seem itchy or have you noticed him/her scratching (including ears), chewing or licking at parts of his/her body?
No
Yes
Please describe
Does your pet have any lumps or bumps that you would like us to examine?
No
Yes
Please describe
Does your pet have any unusual coughing, sneezing or other breathing concerns?
No
Yes
Please describe
Has your pet ever had a reaction to a vaccine?
No
Yes
Please describe which vaccine he/she reacted to and what the reaction looked like:
What is your pet being given for parasite control (flea, tick, heartworm, intestinal parasites), and when was the last dose given?
For Cats Only
Does your pet have any problems with hairballs?
No
Yes
Please describe, including frequency
How many litter boxes do you have in your house, and what type of litter do you use?
Current Medications and Health Conditions
What medications is your pet currently taking? Please include any herbal or “natural” supplements, anything from the human pharmacy and from your own medicine cabinet.
Does your pet have any sensitivities or allergies to food or medication?
No
Yes
Please describe:
Does your pet have any underlying health conditions?
No
Yes
Please describe:
Is there anything else that we should know about your pet?
No
Yes
Please describe:
Do you have any other concerns that you would like to discuss with us? Please list them below:
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New Clients
New Client Registration Form
About Us
Our Team
Gallery
Forms
Patient History Questionnaire – Annual/Vaccine
Patient History Questionnaire – Medical
New Client Registration Form
Services
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
News
Contact Us
Online Store
facebook
instagram