Skip to main content
New Clients
New Client Registration Form
About Us
Our Team
Take A Tour
Pet Gallery
Services
Pet Health
Pet Health Library
Pet Health Checker
Videos
Interactive Animal
Breed Info
Pet Food Recalls
Product Recalls
News
Contact Us
Request An Appointment
Canine History Form
Feline History Form
Pharmacy
twitter
facebook
search
Press enter to begin your search
Canine History Form
Name
First
Last
Phone
Email
Date:
Date Format: MM slash DD slash YYYY
Patient:
Do you use Care Credit/ScratchPay?
Yes
No
Do you want information on financing options?
Yes
No
Do you want information on cutting cost with pet insurance?
Yes
No
Sex:
Male
Female
Spayed/Neuter:
Yes
No
Interested in Spaying/Neutering?
Yes
No
Microchip #:
Interested in Microchipping?
Yes
No
Heartworm Tested?
Yes
No
Interested in Testing?
Yes
No
Age:
Weight:
Nails Long?
Yes
No
Nail Trim today?
Yes
No
Are there other pets in the household?
Canine
Feline
Both Canine and Feline
How many pets live in the household?
Reasons for today’s visit?
Ongoing problems?
Current:
Medications/Supplements:
Any allergies to any medications or vaccines?
Yes
No
What and when?
Diet:
Brand:
Canned?
Yes
No
Dry?
Yes
No
How much do you feed?
How often do you feed?
Recent dietary changes?
What kind of treats / snacks / table scraps / chews do you give your pet?
When is the last time your pet ate?
Parasite Prevention:
What Heartworm Preventative do you give your pet?
What day of the month do you give your pet’s Heartworm Preventative?
Every month?
Yes
No
What Flea and Tick Preventative do you give your pet?
Interested in Heartworm or Flea and Tick Preventative today?
Yes
No
Lifestyle:
Indoor only
Indoor / Outdoor
Outdoor Only
Hunts
Boards
Groomed
Travel
Canine Wellness History Questionnaire
Urine:
Normal
Increased
Decreased
Blood Present
Comments:
Bowel Movements:
Normal
Increased
Decreased
Diarrhea
Constipation
Blood Present
Comments:
Dental Status:
Bad Breath
Sore Gums
Problems Chewing
Drooling
Decreased Appetite
What Dental care do you provide for your pet at home?
Mobility / Activity:
Normal
Unable to jump
Limping
Sore
Painful
Arthritic
Hair / Coat:
Clean and Shiny
Dull
Dandruff
Hair Loss
Mats
Decreased Grooming
Are any Fleas present?
Yes
No
Any bumps or masses that the Doctor should be aware of?
Yes
No
If yes, where and when was it seen, and changes?
Does your pet have any of these symptoms?
Coughing
Vomiting
Diarrhea
Sneezing
Hairballs
Has your pet been seen elsewhere for medical care since we last saw him / her?
Yes
No
If so, when?
Clinics name:
Δ
New Clients
New Client Registration Form
About Us
Our Team
Take A Tour
Pet Gallery
Services
Pet Health
Pet Health Library
Pet Health Checker
Videos
Interactive Animal
Breed Info
Pet Food Recalls
Product Recalls
News
Contact Us
Request An Appointment
Canine History Form
Feline History Form
Pharmacy
twitter
facebook
