Patient History Questionnaire

Today's Date

Pet's Name

Owner's Name

First Last

Reason for your pet's visit today

If applicable, how long has your pet had this problem?

Do you have pet insurance for this pet?

If no, please ask your receptionist for more information regarding pet insurance options, if you are interested.

Please list the name of the insurance company

Is your pet coughing, sneezing, or vomiting?

Please note the amount, how often and when this symptom started

Any other symptoms?

Describe other symptoms

Is your pet having normal stools and urinating regularly?

If not, please describe

What is your pet’s current diet? Please list the brand, the amount fed, and how often the pet is fed.

Is your pet on any medications or nutraceutical supplements at this time?

If yes, please list the medications, the doses of the medications that you gave, and the time that they were given

Do you need any refills of any medications or prevention products at this time?

If yes, please list the medications that you would like refills of

Is your pet on monthly prevention for heartworms, intestinal parasites, fleas and ticks?

If yes, please note the names of the preventative products and where you have purchased them

Is your pet up to date on vaccinations?

If yes, please note the last date given, and if necessary, the hospital/clinic where the vaccines were administered

May we call this location to obtain previous medical history for your pet?

Please note: Proper medical records and a full medical history help us make the best recommendations for your pet!

Does your pet have a history of aggression toward people, other animals, or in a cage?

Please note: If the answer is yes, this does not affect our ability to treat your pet; we will just proceed with caution and be mindful of your pet’s individual needs. We are a Fear Free Hospital and our staff will be more than happy to elaborate on what that means for you and your pet!

In order to keep your pet and our staff safe, please elaborate

Has your pet bitten anyone recently? Does your pet have a bite history?

Please note: If the answer is yes, this does not affect our ability to treat your pet; we will just proceed with caution and be mindful of your pet’s individual needs. We are a Fear Free Hospital and our staff will be more than happy to elaborate on what that means for you and your pet!

In order to keep your pet and our staff safe, please elaborate

Is there anything else that we should know about your pet to help this visit go smoothly (favorite treats, best blood draw sites, helpful handling tips, wary of men/women, white coat syndrome)?

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