New Patient Comprehensive History

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Patient Name *

If first visit, is this your first pet?

Chief Complaint or Reason for Visit *

Has the pet been seen for same condition recently? If so, how recently?

Are vaccinations up to date?
If yes, where were they done last?

Is the pet spayed / neutered?

Has the pet been tested for internal parasites within past 6 months?

Is the pet on heartworm preventive?

Have you seen the pet passing any worms?
If yes, describe

Any injury or illness in past 30 days?
If yes, describe

Does the pet have a history of having seizures?

Is the pet currently on any medications?
If yes, please list

Is the pet allergic to any drugs/medications?
If yes, please list

Diet

How many times / day do you feed your pet?

Pet Treats

Does the pet get table scraps?

Are there any food intolerances?

Did your pet eat this morning?

Appetite

Normal Appetite

Weight

Stable Weight

Water Consumption?

Normal Water Consumption?

Bowel Movements?

Normal Bowel Movements?

Urination?

Normal Urination?

Straining to Urinate?

Vomiting?

Coughing?

Sneezing?

Gagging?

Any Listlessness?

Any Weakness?

Shaking Head?

Scratching?
If yes, where?

Significant Hair Loss?

No Significant Hair Loss?

Flea Control Used?

Frontline® Flea Control Used?

If other, what?

Scooting?

Unusual Lumps or Bumps?

Bad Breath?

Unusual Discharge?
If yes, Location

Lameness?

No Lameness?

Difficulty Rising?
After sleeping?
After Exercise?

Stiffness?

Any Behavioral Changes?
If yes, describe

Any other information we need to know