Healthy Pet Form Healthy Pet Form Name * Name First First Last Last Date Email * Phone * Pet's Name * How do you prefer we report your pet’s fecal & heartworm tests to you? PhoneMailEmail How do you prefer to receive other communications from doctors and staff? PhoneMail Overall Health Does your pet have any allergies to food, vaccines, or medications? NoYes Does your pet have any allergies to food, vaccines, or medications? PLEASE MARK ANY SYMPTOMS OR CONCERNS YOU HAVE ABOUT YOUR PET’S HEALTH TODAY. Is your pet under the care of another veterinarian or health care professional? YesNo Comments Is your pet on medications or supplements? Option 1 Comments What do you feed your pet? * Comments What treats do you give your pet? Comments Changes in eating/appetite? YesNo Comments Diet change in the past month? YesNo Comments Weight change? YesNo Comments Changes in drinking/water consumption YesNo Comments Changes in urination? YesNo Comments Skin changes/itching/rash/lumps? YesNo Comments Eyes redness/squinting/discharge/ vision change? YesNo Comments Ears/head shaking/scratching/odor? YesNo Comments Breathing/coughing/sneezing/gagging? YesNo Comments Teeth/gums/breath odor? YesNo Comments Legs or back/pain/arthritis? YesNo Comments Vomiting? YesNo Comments Normal stools? YesNo Comments Housebreaking concerns? YesNo Comments Spayed or neutered? YesNo Comments Changes with reproductive organs? YesNo Comments Scooting? YesNo Comments Attitude or behavior changes? YesNo Comments Other? YesNo Comments Today's Visit Is your pet current on vaccinations and worming/fecal examinations? YesNo Does your pet need any of the following? Fecal Heartworm Test Nail Trim Microchip Vaccines Other Does your pet need any medications refilled? No YesYes History Lifestyle Indoor Outdoor Companion Dog Performance Dog Breeding Dog Service Dog Describe his or her housing and lifestyle Does your pet travel? In state Out of state Board Dog events Locations Name of Previous Veterinary Clinic Phone Fax Are there tests or x-rays from a previous illness or injury? YesNo If you are new to us, may we request records from your previous veterinarian? Yes Reason you are not at your previous veterinary clinic today? Emergency care not available Dissatisfied with service Dissatisfied with medical care Did not have available appointment Services offered here they do not offer there OtherOther Symptoms Do you have any concerns about your pet’s health? YesNo If Yes, Please Review Below When was your pet last normal? What symptoms have you noticed? What symptoms did you notice first? How long ago? Are the symptoms getting better/ worse/ staying the same? Has your pet been treated for this condition in the past? Describe medications and responses Is your pet acting normally? YesNo Do you have pet health insurance? Yes Preferred Method of Payment Method CashCheckMasterCardVisaDiscoverCare Credit Submit If you are human, leave this field blank.
