Pet Health History

Pet Information

• Animal's Name
• Owner's Name*

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Please answer all questions and elaborate on any abnormal symptoms or behavior in the area provided.
• Reason For Visit*

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• When did you first notice changes?*

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• Appetite*

  • Decreased
  • Normal
  • Increased

  Please make a selection.

• Water Intake*

  • Decreased
  • Normal
  • Increased

  Please make a selection.

• Urination*

  • Less Frequently
  • Normal
  • More Frequently

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• Diarrhea* Yes No

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• Vomiting* Yes No

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• Frequency of Diarrhea?
• If Vomiting, How Often?
• Consistency of Diarrhea?
• Material Vomited?
• Coughing/Sneezing/ Respiratory Problems?* Yes No

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• Walking Normally?* Yes No

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• If yes to respiratory problems, please explain:
• Frequency of Respiratory Issues?
• If no to walking normally, please explain:

• Activity Level*

  • Depressed
  • Normal
  • Above Average

  Please make a selection.

• Skin/Coat (check all that apply)*

  • Dry
  • Normal
  • Oily
  • Itchy
  • Inflamed/Red
• Does your pet have any major medical problems?* Yes No

  Please make a selection.
• Is your pet's vaccinations current?* Yes No

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• If yes to medical problems, please list:
• What kind of pet food do you feed your pet?
• Any other changes in overall health?
• Is your pet on any supplements?
• Do you give your pet people food?* Yes No

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• Is your pet on any medications?* Yes No

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• If yes to people food, please explain:
• If yes to medications, please list:

I understand that diagnostics and treatment may be delayed if I cannot be contacted by phone

• Signature*

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• Primary Contact Number*

  Please enter your phone number.

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• Today's Date*

• Best time to reach you:

  • I agree that that this document may be electronically signed, and that any electronic signature appearing on this document is the same as handwritten signature for the purpose of validity, enforceability, and admissibility.*

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