Patient History Form "*" indicates required fields Name* First Last Pet Name*Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SpeciesCatDogRabbitFerretGuinea PigSmall RodentOtherOtherBreedColorAgeWhat is the primary purpose of today's visit? Are there any specific concerns or problems you wish to make sure are addressed?Does your pet have health insurance?* Yes No Is their microchip up to date?* Yes No What flea, tick and heartworm preventative is your pet receiving? Please specify brand, type and how often they actually receive it.What is your pet's primary diet?How much (cups, ounces, etc) do you feed your pet and how often?What treats, human food and other edibles does your pet get? | Please specify type, size and frequencyHas your pet ever been known to eat wildlife or other "unusual" (non-food) things? If so, what and how often?Are appetite, thirst, urination and defecation normal? Any vomiting or diarrhea?Does your pet cough, sneeze, wheeze or excessively snore? If so, how often and how bad? Also, are there negative effects on behavior, energy, food/water intake, etc?Does your pet travel more than 20 miles from home? Yes No If yes, please specify where (what state, region, etc)Does your pet go for walks in or around the woods or water? Yes No Does your pet socialize with other animals outside the home, such as grooming, boarding, daycare, group training or play dates? If yes: How/where? What kind?What other types (species) of pets or animals do you have (that aren't patients here) which your pet interacts with?Does your pet have any known allergies or sensitivities?Is your pet taking any prescription or OTC supplements or medications? Yes No If yes, please list name, dose and frequency of each.NameDoseFrequency Add RemoveDoes your pet have any prior or ongoing health conditions we should know about?Is your pet sleeping more? Have they slowed down or stopped enjoying normal activities?Does your pet have any behavioral concerns you would like to address?For Cats OnlyFor cats only: Is your cat using their litterbox normally? Yes No For cats only: What type of litter do you use?For cats only: Does you cat play daily? How long/hard?For cats only: Does your cat seek positive attention regularly?For cats only: Does your cat hide a lot or get bullied by other animals/cats in the home?For cats only: Do you observe your cat grooming itself on a regular basis?For cats only: Does your cat go outside the home?YesNoFor cats only: Does your cat go outside the home?YesNoWhere do they go?CatioYard onlyLeash walksFree-roamingWhat percentage of the time is your cat outdoors vs indoors?X/TwitterThis field is for validation purposes and should be left unchanged.
