Patient History Form "*" indicates required fields Name First Last Pet's NameThis field is hidden when viewing the formEmail This field is hidden when viewing the formSpecies Dog Cat This field is hidden when viewing the formGender Female Male This field is hidden when viewing the formEmail To help us give your pet the best care, please take a few minutes to complete this form. Do your best to answer all the questions you can. The more information we have, the better care we can provide for your pet. The veterinarian may also ask for more information during the visit.Indicate in the sections below when each concern started.TODAYYESTERDAY2 DAYS AGO -or- BEFOREIs this condition: Improving Continuing/Unchanging Worsening Has your pet had this problem before? No Yes How long ago?My pet's activity is:Please select all that apply. bright and alert/normal lethargic weak depressed painful other Please describe.My pet feels: normal to the touch warmer than normal colder than normal My pet's appetite is: normal increased decreased My pet's thirst is: normal increased decreased Is your pet experiencing any of the following?Please select all that apply. coughing sneezing nasal discharge difficulty breathing other Please describe.Is your pet experiencing any vomiting? No Yes How often?Please describe what the vomit looks like.Is there blood? No Yes Which of the following best describes your pet's defication/poop normal increased/diarrhea decreased/constipated What does the stool look like?Is there any blood? No Yes Is urination "pee": normal decreased increased Have you noticed any of the following? accidents abnormal color/blood abnormal odor Does your pet have any chronic medical conditions?* No Yes Please select all that apply.* heart murmur seizures cancer diabetes allergies kidney disease other Please explain.*Has your pet ever had a history of injury, trauma, or been diagnosed with a medical illness?* No Yes Please describe.*Did you pet, or his/her littermates, have any problems in kittenhood/puppyhood? No Yes I'm not sure Please describe.*Have you noticed any of the following?Please select all that apply. head shaking scratching scooting other Please describe.*Has there been any possible exposure to poisons?Please select all that apply. expired food prescription medications cleaners rodent killer Other Please describe.*Could your pet have ingested a foreign object?* No Yes Please let us know what you think was ingested.*Please select all that apply. pet toy string trash access to things in the yard other Please describe.*Date of last bloodwork.Date of last x-ray.Date of last fecal analysis.Date of last urinalysis.Did you bring a fecal sample? yes no Has your pet been examined elsewhere for this same condition? No Yes Please tell us when.*Please tell us where.*Are there any known concerns for drawing blood such as:Please select all that apply. clotting disorders anemia venipuncture other Please describe.*My pet is exclusively: indoors mostly indoors exclusively outdoors both indoor + outdoor Are there any other pet's in the household? No Yes Has your pet travelled outside of Michigan? No Yes Is your pet on any medications or supplements?* No Yes Please list all medications and/or supplements.*Have there been any recent changes to the doses of the medications? No Yes Please describe.*Is your pet on any immunosuppressives or chemotherapy? No Yes Do you need refills on any medications? No Yes Please list the medication(s) would you like refilled.*Has your cat ever had a leukemia/FIV test? No Yes Is your pet on flea/tick preventative? No Yes Is your pet on heartworm preventative? No Yes When was the last time your pet was dewormed?Is your pet up to date on these vaccines? Rabies Distemper Bordetella Leptospirosis Select AllHas your pet ever experienced an adverse event or allergic reaction to medications or sedation/anesthesia?* No Yes Please describe.*Any recent weight loss or weight gain? No Yes Any new lumps or bumps? No Yes Please describe.*When was the last time your pet ate?What is your pet's current diet?Please select all that apply. dry food wet/canned food raw diet human food other Please describe.*What brand(s) of food do you feed?How often do you feed your pet? once daily twice daily free choice other Please describe.*Have there been any recent changes in your pet's diet? No Yes Please describe.*Does your pet have any food allergies? No Yes Please describe.*Has you pet ever had a litter? No Yes When was the last heat cycle?Does your pet have a bite history? i.e. biting other pets or people?* No Yes Please describe the circumstances.*Does your pet have any sensitive areas that they do no like to have touched?* No Yes Please check all that apply.* Paws/Nails Anus Mouth Other Please describe.*Did you adopt your pet? No Yes Where did you adopt your pet from?When did you adopt your pet?Do you have any concerns that you would like to bring to the doctor's attention or areas you would like the doctor to pay special attention to while your pet is here? No Yes Please describe*Do you have any pictures of videos that would help us with your pet's exam? No Yes Please upload. Drop files here or Select files Accepted file types: jpeg, png, mpf, Max. file size: 512 MB. Is there anything else we should know about your pet? No Yes Please describe.*
