Patient History Questionnaire – Annual/Vaccine

Client Info

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone you can be reached at today

Alternate Contact Name

First Last

Alternate Contact Phone

Does the Alternate Contact Person have your permission to authorize diagnostic tests or treatments for your pet?

Patient Info

Name

Species

Breed

Sex

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

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?

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?

Please provide details

Does your pet live with any other animals?

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)?

Please describe

Do you have any concerns about your pet’s eating or drinking habits (vomiting, change in appetite or drinking, etc)?

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?

Please describe

Does your pet have any lumps or bumps that you would like us to examine?

Please describe

Does your pet have any unusual coughing, sneezing or other breathing concerns?

Please describe

Has your pet ever had a reaction to a vaccine?

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?

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?

Please describe:

Does your pet have any underlying health conditions?

Please describe:

Is there anything else that we should know about your pet?

Please describe:

Do you have any other concerns that you would like to discuss with us? Please list them below:

Monday	8:30am – 5:30pm
Tuesday	8:30am – 5:30pm
Wednesday	8:30am – 5:30pm
Thursday	8:30am – 5:30pm
Friday	8:30am – 5:30pm
Saturday	Closed
Sunday	Closed