History Form For First Time Patients History Form Client's Name * Client's Name First First Last Last Email * Patient's Name * Date * Where did you get your pet? * Store Breeder Rescue Stray Friend/Relative What diet does your pet eat? * How much do you feed your pet? * When did your pet last eat? * How is your pet’s appetite? * Normal More than normal Less than normal How much water does your pet drink? * Normal More than normal Less than normal How much does your pet urinate? * Normal More than normal Less than normal How are your pet’s bowel movements? * Normal Abnormal Is your pet spayed/neutered? * Yes No How old were they at the time of surgery? * Is your pet primarily indoor, outdoor or both? * Indoor Outdoor Both How is your pet’s activity level? * Normal More than normal Less than normal Has there been any vomiting, sneezing, or coughing? * Are there any other pet’s living in the household and how many? * If yes, are there any illnesses affecting any of them? Has your pet ever lived or traveled outside the MD/PA/DE/DC area & where? Please list any past medical or surgical history For Dogs Has your pet had a heartworm test this year Yes No Is your pet on preventative Yes No Is your pet up to date on the following vaccines & when were they last given? Rabies Distemper Lyme Leptospirosis Bordetella Flu For Cats Has your pet been tested for feline leukemia and/or feline immunodeficiency virus? Yes No Is your pet up to date on the following vaccines & when were they last given? Rabies Feline Distemper Feline Leukemia Medication PLEASE LIST ALL MEDICATION YOUR PET IS CURRENTLY ON, INCLUDING MEDICATION NAME, STRENGTH, AMOUNT YOU ARE GIVING, AND HOW OFTEN Medication Strength Amount Given How Often plus1 Add another medication minus1 Remove a medication Preferred pharmacy name/location Captcha Submit If you are human, leave this field blank.
