Patient History Form

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Patient History Form

Please fill out this form for each pet we will be visiting now or in the future.

1
Your Name* This field is required
First Name
Last Name
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2
Email* This field is required
example@example.com
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3
Pet's Name* This field is required
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4
Cat or Dog* This field is required
Cat
Dog
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5
Does your cat go outdoors or stay indoors?* This field is required
Exclusively indoor
Exclusively outdoor
Both Indoor and outdoor
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6
Do you regularly apply flea control?* This field is required
YESNO
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7
Please enter the brand of flea control, if known.
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8
Which vaccines does your cat usually receive?* This field is requiredCheck all that apply.
Rabies
FeLV (Feline Leukemia)
FVRCP (Feline Viral Rhinotrachetis, Calicivirus, Panleukopenia/Distemper)
My cat does not usually receive vaccines.
My cat is regularly vaccinated, but I'm not sure which vaccines are given.
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9
Which vaccines does your dog usually receive?* This field is requiredCheck all that apply
Rabies
DA2PP (Distemper, Adenovirus-2, Parainfluenza, Parvo)
Leptospirosis
Bordetella (kennel cough)
Canine Influenza
My dog is regularly vaccinated, but I'm not sure which vaccines are given.
My dog does not receive vaccinations.
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10
Will your dog need any vaccines administered during your visit?* This field is required
Yes
No
I would like to discuss vaccines with the doctor before I decide.
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11
Will your cat need any vaccines administered during your visit?* This field is required
Yes
No
I would like to discuss vaccines with the doctor before I decide.
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12
Which vaccines does your cat need during this visit?* This field is requiredCheck all that apply
Rabies
FeLV
FVRCP
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13
Which vaccines does your dog need during this visit?* This field is required
Rabies
DA2PP
Leptospirosis
Bordetella (kennel cough)
Canine Influenza
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14
Does your dog receive a heartworm preventative?* This field is required
YESNO
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15
Which heartworm preventative does your dog receive?* This field is requiredInterceptor Plus, Heartgard, Trifexis, Revolution, Sentinel, etc.
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16
Is your pet currently receiving any medications, herbs or supplements?* This field is required
YESNO
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17
Please list all medication, herbs or supplements your pet is currently receiving.* This field is required
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Ok
Ok
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18
Has your pet been previously diagnosed with any specific illness, condition, or had any surgical procedure (other than spay or neutering)?* This field is required
YESNO
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19
Please list/describe any previously diagnosed illnesses, chronic or terminal conditions and past surgeries.* This field is required
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Ok
Ok
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20
Does your pet have any current injuries or wounds?* This field is required
YESNO
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21
Please describe any injuries or wounds and what part of the body they are located.* This field is required
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Ok
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22
Please describe what foods and treats your pet is currently eating.* This field is required
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Ok
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23
Has your pet's diet remained unchanged for the past 60 days?* This field is required
YESNO
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24
Please describe what changes you've made to their diet.* This field is required
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Ok
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25
Does your pets appetite appear normal?* This field is required
YESNO
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26
Please describe what you've observed about your pet's appetite.* This field is required
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Ok
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27
Does your pet's weight appear normal?* This field is required
YESNO
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28
Please describe what you've observed about your pet's weight.* This field is requiredIs s/he overweight or underweight? Has s/he been losing weight or gaining weight recently? Describe how s/he appears to you.
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Ok
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29
Has your pet been vomiting recently?* This field is required
YESNO
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30
Please describe the vomiting* This field is requiredHow long has this been going on? How many times has s/he vomited, or if chronic, how frequently does vomiting occur? Does the vomiting seem to be associated with eating, or not? Can s/he keep water down?
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Ok
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31
Does your pet's stool appear normal?* This field is requiredFirm, well formed, not too wet or dry, etc. **For annual exams, please have a fresh stool sample available whether it appears normal or not.**
YESNO
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32
Please describe your pet's stool.* This field is requiredDiarrhea? Pudding-like or watery? Contains blood or mucus? How often and how long as it been going on? Dry and hard or straining to defecate? Several days since last bowel movement? **If your pet's stool is abnormal, please have a fresh stool sample available if possible at time of visit.**
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Ok
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33
Does your pet's water intake seem normal?* This field is required
YESNO
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34
Please describe your pet's drinking habits.* This field is requiredAre they drinking more or less frequently? Are they drinking more volume or less volume? Do they seem thirsty all the time? Do they never seem thirsty? Other observations?
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Ok
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35
Do your pet's urination habits seem normal?* This field is required
YESNO
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36
Describe your pet's urination habits.* This field is requiredAre they urinating a larger/smaller volume? Do they need to go more/less often? Are they having accidents in the home? Do they strain to go or is there any observable pain? Other observations?
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Ok
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37
Please describe your cat's current use of their litter box.* This field is required
Eliminates inside a litter box all the time.
Eliminates outside the litter box (indoors) occasionally.
Eliminates outside the litter box (indoors) frequently or all of the time.
Eliminates outdoors and does not use a litter box.
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38
How long has your cat been eliminating outside the litter box?* This field is required
Just started today
The last few days.
The last few weeks.
The last few months or longer
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39
Does your pet's skin, coat or fur seem to be normal?* This field is required
YESNO
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40
Describe what seems abnormal about your pet's skin, coat and/or fur.* This field is required Are there open sores or wounds? An odor? Are there red areas or unusual markings on the skin?
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Ok
Ok
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41
Does your pet frequently scratch or chew a particular area (or areas) of their body?* This field is required
YESNO
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42
Please describe what area of your pet's body seems to be most itchy.* This field is requiredEntire body. Around ears, face, sides, etc.
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Ok
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43
Does your cat seem to be grooming normally?* This field is required
YESNO
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44
Describe your cat's grooming habits.* This field is requiredDoesn't seem to groom anymore? Is there a part of the body s/he grooms over and over frequently? What part of the body? Other observations?
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Ok
Ok
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45
Do you have any concerns about your pet's activity level?* This field is required
YESNO
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46
Describe what you have observed about your pet's activity level.* This field is requiredHyperactive? Restless? Lethargic or more sedentary? Sleeping more or less than usual? Pacing?
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Ok
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47
Do you have any mobility concerns about your pet?* This field is required
YESNO
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48
Describe the mobility concerns you have about your pet.* This field is requiredDifficulty standing? Limping? Moving stiffly? Moves with pain? Only stands with assistance? Other observations?
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Ok
Ok
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49
Do you have any behavior concerns about your pet?* This field is required
YESNO
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50
Describe the behavior that concerns you.* This field is requiredAggressive with other pets or with people? Inappropriate urination or defecation? Spraying? (cats). Damages furniture? Seems stressed or anxious? Other observations?
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Ok
Ok
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51
Do you have any specific health concerns not previously described that you would like the doctor to address?* This field is required
YESNO
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52
Please describe the other health concerns you have about your pet at this time.* This field is required
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Ok
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53
What are your goals for your home visit with the doctor?* This field is required
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Ok
Ok
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54
Do you have another pet history to add?* This field is requiredIf you select "Yes" you will be taken back to the beginning of this form to enter another pet history.
YESNO
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55
Please verify that you are human* This field is required
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