Comprehensive Pet History Form

Client Name (First & Last):

Phone Number:

Email Address:

Pet's Name:

Select One:
MaleFemaleSpayedNeutered


Diet & Weight

Please be as specific as possible.

Brand of Food:

Amount & Frequency:

Brand of Treats:

Amount & Frequency:

Table scraps?
YesNo

Change in frequency?
YesNo

Weight loss/gain?
YesNo

On a diet?
YesNo

Appetite:
IncreasedDecreasedNormal

Water Consumption:
IncreasedDecreasedNormal


Dental

Last Dental

Brush teeth?
YesNo

Use dental products?
YesNo

Drop food/drool?
YesNo


Vaccinations/Prevention

Please select all vaccinations your pet has received:
Distemper/ParvoLeptospirosisRabiesHeartworm TestBordetellaFluLyme DiseaseRattlesnakeFVRCPFelV/FIV TestFelV

Annual lab work?
YesNo

Urinalysis?
YesNo

Has your pet ever had any vaccine reactions?
YesNo

If yes, please describe:

Heartworm prevention used?
YesNo

If yes, what type and when was it last administered?

Flea control used?
YesNo

If yes, what type and when was it last administered?

Has your pet ever been dewormed?
YesNo

Are you seeing fleas on your pet?
YesNo

Have you sprayed the house/yard?
YesNo


Urination/Defecation

Urination:
NormalIncreasedDecreased

Spraying/marking?
YesNo

Using the litterbox?
YesNo

Defecation:
NormalAbnormal

Diarrhea?
YesNo

Seeing worms?
YesNo

For cats, are there any problems with litter box use or behavior?
YesNoN/A

If yes, please describe:


Behavioral

Is your pet agressive?
YesNo

Any increased vocalization?
YesNo


Skin

Itching?
YesNo

Seasonal?
YesNo

Hair loss?
YesNo

Has it gotten worse with age?
YesNo


Sick/Injured

History of seizures?
YesNo

Please list all current medications - include over-the-counter medications, nutritional supplements, and herbal medications.

Medication 1:

Name:

Dose:

Frequency:

Medication 2:

Name:

Dose:

Frequency:

Medication 3:

Name:

Dose:

Frequency:

Please check all symptoms that currently apply to your pet.
VomitingGaggingListlessnessShaking HeadLumps/BumpsCoughingSneezingWheezingScootingDischargeWatery Eyes or Nose


Musculoskeletal

Has your pet ever had orthopedic surgery?
YesNo

If yes, please describe:

Please check all symptoms that currently apply to your pet.
LamenessDifficulty RisingDifficulty JumpingStiffnessTrouble with Stairs


Environmental

If you have other pets, please list what breed and how many:

Allowed to run on acreage?
YesNo

Do they go hunting?
YesNo

Are there children in the house?
YesNo

Do they see a groomer?
YesNo

Have they ever been to a boarding facility?
YesNo

Please select:
Indoor OnlyOutdoor OnlyIndoor and Outdoor

If outdoor, what type of outside access does your pet have?


Chief Complaint

List any symptoms, concerns, etc. that you have with your pet's health: