Patient History Form

This form must be completed 48 hours prior to your appointment. If your appointment was scheduled less than 48 hours before your appointment time please complete it as soon as possible. This form helps expedite your visit and ensures your veterinary staff can best care for your pet.

Patient Name*

Species

Breed

Color

Patient DOB

Sex

Male Intact

Male Neutered

Female Intact

Female Spayed

Insurance*

Yes

Appointment Date*

Appointment Time*

What is the primary purpose of your pet's appointment today?(If your pet is here for a progress evaluation, do you think your pet is doing better?)*

Is your pets energy level normal, if not please explain*

Is your pet eating and drinking normally? If not, please explain*

Does your pet have any vomiting? Please describe (when did it start, how frequently does it occur, etc)*

Does your pet have diarrhea? Please describe*

Does your pet cough, sneeze, have eye or nasal discharge? Please describe*

Does your pet have any ear or skin problems? Please describe*

Does your pet have any mobility problems? Please describe*

Does your pet have undesirable behaviors you wish to discuss?*

What do you feed your pet? (brand, type, frequency, amount)*

What and how often does your pet get treats or human food?*

Non-Food Ingestion (Plants, other medication, toys, fecal matter, garbage)?*

What medications is your pet on? (Name, strength, frequency, do you need refills)*

What supplements do you give your pet? (Name and frequency)

What flea preventive do you use and when was it last administered?*

What heartworm preventive do you use and when was it last administered?*

Do you have other pets in the home?*

Yes

Has your pet been treated by any other veterinary care providers since their last visit at Pacific Heights Veterinary Hospital?*

Does your dog go to dog parks, doggie daycare, etc?

What percent of the time does your cat spend outside?

Is your cat using the litter box appropriately?

What other questions or concerns do you wish to address with your veterinary team?