Patient History Form Please complete this form ahead of time to help us prepare for your pet’s visit. Client Name(Required) First Last Email(Required) Patient Name(Required) Patient Birthday(Required) Why are they asking me this? Don't they have this in my pet's records? We often get asked why we go over the same questions for your pet at each visit. While we do have most things documented in our records, we know that things can change and it is really important from a medical standpoint for our doctors to know what is true at the time of each visit. Just like you get asked the same questions about your medical history every time you go to your doctor's office, the same is true for your pets. For instance, medications might have been dispensed or adjusted by another vet or specialist. They might have recommended you change how much or how often you are giving a particular medication that we might not have documented in our records. This is just one example of how things can change, and why it is important that we ask at every visit to make sure your pet's medical record is up to date. Verifying this information every time is essential so that you can trust that the recommendations our doctors make are complete, accurate, and safe for your pet. Please answer the following questions to the best of your ability and be specific as possible, especially with details about medication dosing.(Required) I understand. What is your pet being seen for?(Required) Puppy/Kitten Visit Adult Wellness Visit Senior Wellness Visit Sick Visit Follow-up Visit Consultation Is your pet on Heartworm Prevention?(Required) Yes No Name of Heartworm Prevention(Required) Date of last dose given(Required) Is your pet on Flea/Tick Prevention?(Required) Yes No Name of Flea/Tick Prevention(Required) Date of last dose given(Required) Is your pet on any medications or supplements given regularly? (Ex: daily, every other day, etc.)(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex. "Vetprofen 25 mg"(Required) Dose and Frequency - Ex. "1 tablet every 12 hours"(Required) Does your pet receive any medications or supplements to help with anxiety for stressful events? (Ex: vet visits, fireworks, etc.)(Required) Yes No Name and Strength of Medication or Supplement - Ex: "Trazodone 50 mg"(Required) Dose and Directions - Ex: "1 tablet 2 hours before vet visits"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex: "Trazadone 50 mg"(Required) Dose and Directions - Ex: "1 tablet 2 hours before vet visits"(Required) Do you have another medication or supplement to add?(Required) Yes No Name and Strength of Medication or Supplement - Ex: "Trazadone 50 mg"(Required) Dose and Directions - Ex: "1 tablet 2 hours before vet visits"(Required) Do you need refills of any preventatives, medications, or supplements?(Required) Yes No What do you need a refill of?(Required) Where does your pet spend most of their time?(Required) Primarily Indoors Primarily Outdoors Half/Half What brand and type of food are you currently feeding your pet?(Required) How often do you feed your pet?(Required) Once a day Twice a day Free feed Other Please explain(Required)Amount you are feeding per meal(Required) Is it grain free?(Required) Yes No Unsure Please list any additional pets in the home.(Required)Bring a fresh stool sample for intestinal parasite testing. Puppies and kittens have intestinal parasites that are transmitted from their mother. This is normal, but some of these parasites can be transmitted to people, too. That's why it's so important for us to test your puppy or kitten at each visit. Please bring a stool sample with you for this visit.(Required) I understand. Sample Collection: A fresh sample can be up to 12 hours old as long as it was collected right when it was produced. Refrigeration is preferred but not required. For dogs: There are parasites that live in the soil, and if the sample is left out in the yard for any period of time, it can become contaminated. For cats: Collect a sample from the litterbox. If it is covered with litter, that's ok. Litter will not affect the test results. Bring a fresh stool sample for intestinal parasite testing. Intestinal parasites are highly prevalent in our area? Some of these parasites can also be transmitted to people. That's why it is so important for us to test your pet at least once a year. Please bring a stool sample with you for this Adult Wellness visit.(Required) I understand. Bring a fresh stool sample for intestinal parasite testing. Intestinal parasites are highly prevalent in our area? Some of these parasites can also be transmitted to people. That's why it is so important for us to test your pet at least once a year. Please bring a stool sample with you for this Senior Wellness visit.(Required) I understand. Sample Collection: A fresh sample can be up to 12 hours old as long as it was collected right when it was produced. Refrigeration is preferred but not required. For dogs: There are parasites that live in the soil, and if the sample is left out in the yard for any period of time, it can become contaminated. For cats: Collect a sample from the litterbox. If it is covered with litter, that's ok. Litter will not affect the test results. Sample Collection: A fresh sample can be up to 12 hours old as long as it was collected right when it was produced. Refrigeration is preferred but not required. For dogs: There are parasites that live in the soil, and if the sample is left out in the yard for any period of time, it can become contaminated. For cats: Collect a sample from the litterbox. If it is covered with litter, that's ok. Litter will not affect the test results. Bring a fresh stool sample for intestinal parasite testing. If your pet is being seen for any type of gastrointestinal issues, please bring a stool sample with you for this visit. Intestinal parasites are highly prevalent in our area, and some parasites can also be transmitted to people. That's why it is so important for us to test your pet if they are showing symptoms, like diarrhea or vomiting.(Required) I understand. Bring a fresh stool sample for intestinal parasite testing. If your pet is being seen for a follow-up regarding any type of gastrointestinal issues, please bring a stool sample with you for this visit. Intestinal parasites are highly prevalent in our area, and some parasites can also be transmitted to people. That's why it is so important for us to test your pet if they are showing symptoms, like diarrhea or vomiting.(Required) I understand. Sample Collection: A fresh sample can be up to 12 hours old as long as it was collected right when it was produced. Refrigeration is preferred but not required. For dogs: There are parasites that live in the soil, and if the sample is left out in the yard for any period of time, it can become contaminated. For cats: Collect a sample from the litterbox. If it is covered with litter, that's ok. Litter will not affect the test results. Sample Collection: A fresh sample can be up to 12 hours old as long as it was collected right when it was produced. Refrigeration is preferred but not required. For dogs: There are parasites that live in the soil, and if the sample is left out in the yard for any period of time, it can become contaminated. For cats: Collect a sample from the litterbox. If it is covered with litter, that's ok. Litter will not affect the test results. CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
