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Patient History Form

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Select a location*

Client's First Name*

Client's Last Name*

Pet's Name*

Primary Contact Name*

Primary Contact Phone Number*

Name of person who will be present for consultation*

Your pet's current medications (name, dose, and how often you give it)*

Reason for Visit (please be as detailed as possible about what you've seen and why you scheduled a consultation)*

Any other concerns (your veterinarian will do their best to address these if there's enough time)*

CURRENT HISTORY

Is your pet vomiting? If so, how often and for how many days? What does the vomit look like?*

Does your pet have diarrhea or soft stool? If so, how often? If so, is there any blood or mucous in the stool? If so, for how many days?*

Is there any sneezing or nasal discharge? If so, how often and for how many days?*

Is there any coughing (if so, is it dry/wet)? If so, how often and when did it start?*

How is your pet’s energy level (i.e. normal, increased, decreased)?*

Are their bathroom habits normal? If not, please explain what's not normal.*

Environment: Any other pets in the household? If so, please provide a brief description. Apartment or house (do you have a yard, go to dog park, etc)? Have there been any changes to your home environment in the last few weeks or months? (ex. someone moved in, someone moved out, construction, etc.).*

Has your pet traveled outside of the DC area? If so, when and to where?*

Do you believe your pet in pain (if so, how is he/she expressing the pain)? When did you notice these symptoms?*

What is your pet’s main diet? (please include brand, amount, and how often are they eating). Does your pet get any treats or human foods? If so, what and how often?*

PAST HISTORY

Any past medical problems?*

Any major or minor surgeries?*

Any medications your pet has been on in the last 12 months that they are no longer taking? If so, why did they stop taking this medication?*

Name

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