Patient History Form Owner's Name* First Last Date of BirthPatient Name*Breed*Sex*Color*VeterinarianDate MM slash DD slash YYYY Preventative MaintenanceBody ConditionGaining Weight? Yes No Losing Weight? Yes No Food IntakeType of food given?Appetite Increased Decreased Not Eating Oral HealthOdor/Bad Breath Yes No Paws or Rubs Face Yes No Drops Food Yes No Avoids Facial Contact Yes No Water IntakeIncreased? Yes No Decreased? Yes No For how long?UrinationIncreased? Yes No Decreased? Yes No Leaking Yes No Accidents Yes No Marking Yes No Difficulty / Pain Yes No Appearance change Yes No Odor change Yes No DefecationAppearance change Yes No Color change Yes No Mucous Yes No Blood Yes No Accidents in house Yes No Incontinence Yes No No feces Yes No VomitingAppearanceFrequencyBreathingCoughing Yes No Labored Yes No Abnormal noise Yes No Increased panting Yes No Change in bark / meow Yes No ExerciseReluctant Yes No Disinterested Yes No Fatigues quickly Yes No Painful Yes No Pain AssessmentStiffness Yes No Lies in odd positions Yes No Reluctant to lie down Yes No Reluctant to move Yes No Change in gait Yes No HairCheck all that apply Thinner Different color Patchy Slow growth Bald spots Dry Oily SkinCheck all that apply Redness Itching Irritation Dry/Flakey Lesions Medications / SupplementsPrescription medicineSupplements / VitaminsRoutine heartworm prophylaxis Yes N0 Routine flea & tick preventative Yes No Mentation, Vision, HearingCheck all that apply Personality change Anxious Nervous Fearful Confused / Disorientated Difficulty navigating familiar areas Difficulty navigating unfamiliar areas Difficulty navigating dark environments Does not respond when called Startled if approached from behind Lumps & BumpsPlease listLocationSwelling (Y/N)Bleeding (Y/N)Growing (Y/N)Irritated (Y/N) Any other questions / observations or concerns?Are other pets in household current on vaccinations? Yes No PhoneThis field is for validation purposes and should be left unchanged.
