Drop Off Patient History Form Drop-off Patient History Form Name * Name First First Last Last Pet's Name * Phone * Email * Reason for visit Annual Exam/No Concerns Annual Exam/Concerns Listed Below Sick Exam Sick Exam - vaccines if able (see consent form) Please list and describe any concerns, issues or problems below When did problem(s) start? Are problem(s) getting Worse Better Same What type of food are you feeding your pet. Check all that apply Canned Kibble/Dry bag food Raw Home Cooked Brand/type of food How many times per day do you feed? 1 2 3 Leave it out all the time How much food do you put out each time? Do you give treats? Yes No If so how many and what kind? Eating habits: Check all that apply Eating Normally Difficulty or painful when eating Eating more than usual Not eating as much Not eating at all Drinking habits: Check all that apply Drinking normally Drinking excessively Not drinking much or at all Urination habits: Check all that apply No problems with urination Small urine puddles Bloody urine Leaking urine while sleeping Not using litter box sometimes or at all LARGE urine puddles Smelly urine Frequent urination Painful when trying to urinate Straining when trying to urinate Color of urine Defecation habits: Check the best representation of your pet’s stools *Click to view image guide 1. Very hard and dry, Often expelled as individual pellets, Requires much effort to expel from body, Leaves no residue on ground when picked up 2. (ideal) Firm, but not hard, pliable, Segmented in appearance, Little or no residue on ground when picked up 3. Log shaped, moist surface, Little or no visible segmentation, Leaves residue on ground, but holds form when picked up 4. Very moist and soggy, Log shaped, Leaves residue on ground and loses form when picked up 5. Very moist but has a distinct shape, Present in piles rather than logs, Leaves residue on ground and loses form when picked up 6. Has texture, but no defined shape, Present as piles or spots, Leaves residue on ground when picked up 7. Watery, No texture, Present in flat puddles Is your pet on any Flea/Tick/Heartworm Preventatives? Yes No Product's Name Date Last Given Cat Only Question: Check the option that applies Indoor Only Strictly Outdoors Indoor/Outdoor My pet is anxious about: (Check all that apply) Fireworks Loud Noises Other animals New People Veterinary Hospitals Everything When I leave him/her alone OtherOther When my pet is upset he/she reacts: (Check all that apply) Aggressively Hides Runs away Urinates Growls/Hisses but doesn’t act out Destroys things OtherOther I would like anxiety meds for my pet Yes No List any medications that your pet is currently taking other than preventatives List any Supplements that your pet is currently taking (natural products like vitamins or CBD) Do you need/want any medications or supplements dispensed or refilled today? Yes No (outside of what is needed for illness found during visit) If yes, what and how much? Any follow up questions or concerns specifically for the doctor? Captcha Submit If you are human, leave this field blank.
