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Patient History Form (Canine/Feline)
Patient Information
Patient Name
First
Breed
Age
Sex
M
MN
F
FS
Chief Complaint/Reason for Visit
Ongoing Conditions
Additional Concerns
Current Medications
Known Allergies
Current Diet
Wet
Dry
Table Food
Treats
Other
If other, please specify
Heartworm Preventions
Date given
Date Format: MM slash DD slash YYYY
Flea Preventions
Date given
Date Format: MM slash DD slash YYYY
Date of Last Bath/Grooming
Date Format: MM slash DD slash YYYY
Health Information
Cardiovascular/Respiratory
Coughing
Yes
No
Anything produced from cough?
Sneezing
Yes
No
Any discharge/describe
Wheezing
Yes
No
Difficulty Breathing (Tail bob)
Yes
No
Exercise intolerance
Yes
No
Fainting or Weakness
Yes
No
Retching or Gagging
Yes
No
Unusual Noises/Swelling
Yes
No
Skin
Itching
Yes
No
Location
Hair loss
Yes
No
Location
Dandruff or Dry skin
Yes
No
Odor or pigment changes?
Yes
No
Masses or Swellings?
Yes
No
If yes, please describe
When is it worse?
Seasonal
Continuous
Which Season?
Do medications help?
Yes
No
Temporary
GI/Digestive
Possibility of Foreign Body Ingestion
Yes
No
Vomiting
Frequency
Describe
Diarrhea or Constipation
Less
Normal
Color change
Normal timing
Watery
Blood
Dry
More
Blood in stool
Yes
No
If yes, please describe
Mucous
Yes
No
Any known triggers
How long?
Ears
Shaking Head or scratching
Yes
No
Discharge/Odor
Yes
No
If yes, please specify
Swelling
Yes
No
Pain
Yes
No
Heat
Yes
No
Hearing Loss
Yes
No
Which ear
Left
Right
Both
Cleaning at home? How Often and with What?
Eyes/Head/Neck
Swelling or asymmetry
Yes
No
Nasal Discharge
Yes
No
If yes, please describe
Red eye or color change
Yes
No
Describe
Vision Changes
Yes
No
Pain (rubbing or avoiding light)
Yes
No
Allergies
Yes
No
Smoking or Candles around pet
Yes
No
How long has this been noticed
Which eye affected
Left
Right
Both
Musculoskeletal
Difficulty Rising/Jumping
Yes
No
Stumbling or Falling
Yes
No
Shaking or Tremors
Yes
No
"Walks it off after a few minutes"
Yes
No
Non Weight bearing
Yes
No
Luxating Patella
Yes
No
Ongoing issues
Yes
No
If yes, please describe
History of trauma?
Yes
No
If yes, please describe
Legs affected
RF
LF
RH
LH
Neurological
Head Tilt
Yes
No
Change in attitude or behaviors
Yes
No
If yes, please describe
Seizures
Yes
No
if yes, when was the last seizure?
How many in a month?
Length of Seizure
Medications
Memory loss/confusion
Yes
No
Sudden Blindness or Deafness
Yes
No
Muscle weakness
Yes
No
If yes please tell us when it started
Oral / Dental
Odor
Yes
No
Gingivitis (redness of gums)
Yes
No
Growths or Masses
Yes
No
Unexplained swelling
Yes
No
Painful
Yes
No
Difficulty swallowing/eating
Yes
No
Drooling
Yes
No
Teeth Discoloration
Yes
No
Loose teeth
Yes
No
Please describe concerns
Urinary
Frequent Urination
Yes
No
Increased water consumption
Yes
No
If yes, please describe
Blood in Urine
Yes
No
Amount
Clots
Vulvar discharge
Yes
No
Penile discharge
Yes
No
Straining to urinate
Yes
No
Unable to urinate
Yes
No
History of being blocked
Yes
No
If yes, please specify when?
Dribbling urine
Yes
No
Urinating in inappropriate areas
Yes
No
How long happening?
Reproductive
Spayed or Neutered
Yes
No
Previous litters
Date
Date Format: MM slash DD slash YYYY
Number of litters
Please enter a number from
0
to
100
.
Date of Last Heat Cycle
Date Format: MM slash DD slash YYYY
Problems with whelping/queening?
Testicular swelling/size change
Other concerns
Masses or Growths
Location
Yes
No
If yes, please describe
When did it appear?
History of cancer?
Yes
No
If yes, please describe
Mass growth
Yes
No
Ulceration or bleeding
Yes
No
Bothering pet
Yes
No
Mobile
Yes
No
Diameter of mass
Yes
No
Soft
Yes
No
Hard
Yes
No
Discharge
Yes
No
If yes, please describe
Ongoing History
Vaccines History Vaccines and date given
Rabies
1yr
3yr
Other
If other, please specify when
DH2PP (Distemper)
Leptospirosis
Bordetella (Kennel Cough)
Influenza
Lyme
FVRCP (Feline Distemper)
FeLV
FIV
If other, please describe
Testing
Heartworm
Yes
No
Anaplasmosis
Yes
No
Ehrlichiosis
Yes
No
Lyme
Yes
No
FeLV/FIV
Yes
No
Any vaccine reactions in the past?
Any IMHA or other immune diseases?
Was a full puppy or kitten series given?
Any other pertinent history you want us to know?
Today's Date
*
Date Format: MM slash DD slash YYYY
Typed Signature
*
Signature
Consent
*
I agree to the privacy policy.
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New Clients
New Client Registration Form
Patient History Forms
About Us
Services
Patient Resources
Online Pharmacy
Follow Up Survey
Forms
Payment Options
Pet Health
Interactive Animal
Breed Info
Pet Health Library
Videos
Pet Health Checker
Pet Insurance
News
Contact Us
Prescription Refill and Food Order Request Form
Curbside Care Form
