Patient History Questionnaire – Medical – Clinton Veterinary Services

Patient History Questionnaire - Medical

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
My concern(s) for my pet is/are:
The last time my pet was his/her normal self was
My pet’s energy level seems to be
Diet
My pet's water intake is:
My pet's appetite is:
The last normal meal that my pet has eaten was on:
Date Format: MM slash DD slash YYYY
My pet has been vomiting
If vomiting has been noted, please describe what your pet has been bringing up:
What does your pet usually eat? Please include any table scraps, treats, and “people food”:
Is there a possibility that your pet has eaten anything other than his/her normal diet (including a different brand of food, table scraps, raiding the garbage, toxins, chewing on toys or other objects, etc.)?
Please describe:
Elimination
My pet's stools are:
If you have seen diarrhea, please describe the texture and colour:
When did you first notice the diarrhea?
Date Format: MM slash DD slash YYYY
My pet has been urinating:
Have you noticed a change in the urine?
Please describe the changes
Is your pet straining to urinate?
For Cats Only
Has your pet been urinating or defecating outside of the litter box?
Which are you finding outside of the box?
Respiratory
Has your pet been coughing?
Have you noticed and licking or swallowing after coughing?
Has your pet been sneezing?
Have you noticed any discharge from your pet’s nose?
What does the discharge look like? Check all that apply:
- Clear
- Yellow/Green
- Bloody
- Runny
- Thick
Mobility, Pain, Trauma
My pet is (check all the apply):
- Limping
- Seems sore
- Has been injured
What body part do you think is bothering them?
Please provide details
This started on:
Date Format: MM slash DD slash YYYY
It has since:
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:

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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

Patient History Questionnaire - Medical

Client Info

Patient Info

Diet

Elimination

For Cats Only

Respiratory

Mobility, Pain, Trauma

Current Medications and Health Conditions

Contact Us

Hours of Operation

Emergency Info