Comprehensive Pet History

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Last Name:

Pet Name:

Is your address & phone number still correct?
Yes No

Are you aware pet insurance is available? Yes No

Will your pet need additional restraint for the exam?
(ie: history of snapping, aggressive behavior)
YesNo

Is your pet current on all vaccinations? Yes No

Is your pet spayed or neutered? Yes No

Is your pet on heartworm prevention? Yes No

Type: Heartgard Sentinel Revolution
Other:

Flea control used? Yes No

Type: Frontline Advantage Sentinel
Other:

Has the pet been passing worms? Yes No
Description:

Any injury or illness in the past 30 days? Yes No
Describe:

Does the pet have a history of having seizures?
Yes No

Is your pet currently on any medications? Yes No
If so, what medication(s):

Is your pet allergic to any drugs/medications?
Yes No

If so, to what:

What food is your pet currently eating?

Are there any food intolerances/ allergies? Yes No
If so, to what?

Shaking Head? Yes No

Scratching? Yes No

Location:

Hair Loss?
Yes No Patchy General Excessive shedding

Scooting? Yes No

Weakness? Yes No

Vomiting? Yes No

Coughing? Yes No

Gagging? Yes No

Sneezing? Yes No

Lethargy? Yes No

Appetite: Increased Normal Decreased

Weight: Lost Stable Gain

Water Consumption: Increased Normal Decreased

Bowel Movements: Constipated Normal Diarrhea
How Long:

Urination:
Normal Increased Amount Increased Frequency

Straining to urinate? Yes No

Any lumps or bumps? Yes No
Where?

Bad breath? Yes No

Lameness/ Stiffness? Yes No
Which leg(s):

Difficulty rising? Yes No

After sleeping? Yes No

After exercise? Yes No

Any Behavioral Changes? Yes No
Describe:

Any other concerns?


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