Patient History Form Owner's Name* First Last Date of BirthPatient Name*Breed*Sex*Color*VeterinarianDate Date Format: MM slash DD slash YYYY Preventative MaintenanceBody ConditionGaining Weight?YesNoLosing Weight?YesNoFood IntakeType of food given?AppetiteIncreasedDecreasedNot EatingOral HealthOdor/Bad BreathYesNoPaws or Rubs FaceYesNoDrops FoodYesNoAvoids Facial ContactYesNoWater IntakeIncreased?YesNoDecreased?YesNoFor how long?UrinationIncreased?YesNoDecreased?YesNoLeakingYesNoAccidentsYesNoMarkingYesNoDifficulty / PainYesNoAppearance changeYesNoOdor changeYesNoDefecationAppearance changeYesNoColor changeYesNoMucousYesNoBloodYesNoAccidents in houseYesNoIncontinenceYesNoNo fecesYesNoVomitingAppearanceFrequencyBreathingCoughingYesNoLaboredYesNoAbnormal noiseYesNoIncreased pantingYesNoChange in bark / meowYesNoExerciseReluctantYesNoDisinterestedYesNoFatigues quicklyYesNoPainfulYesNoPain AssessmentStiffnessYesNoLies in odd positionsYesNoReluctant to lie downYesNoReluctant to moveYesNoChange in gaitYesNoHairCheck all that apply Thinner Different color Patchy Slow growth Bald spots Dry OilySkinCheck all that apply Redness Itching Irritation Dry/Flakey LesionsMedications / SupplementsPrescription medicineSupplements / VitaminsRoutine heartworm prophylaxisYesN0Routine flea & tick preventativeYesNoMentation, 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 behindLumps & 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?YesNoEmailThis field is for validation purposes and should be left unchanged.
