Pet Check-In/History Form Owner Name* First Last Phone*If you are NOT the one bringing your pet for the appointment, please also list the name and phone number of the person bringing them:Caretaker Name First Last Caretaker PhoneDate of appointment:* MM slash DD slash YYYY Time of appointment:* : Hours Minutes AMPM AM/PMMake, model, and color of the vehicle you and your pet will be in:*Are you bringing your pet in for one of the following visits:* Wellness/Annual/Biannual Exam Sick VisitWellness/Annual/Biannual ExamPet's Name*Is your pet having any issues (vomiting, diarrhea, coughing/sneezing, new or changing growths, mobility problems etc.)?* Yes NoIf Yes, please elaborate*Is your pet experiencing any behavioral changes (change in appetite, increased drinking/urination, etc.)?)* Yes NoIf Yes, please elaborate:*Current diet:*Any medications and/or supplements:*What type of flea/tick control do you use?*When was the last dose given?*What type of heartworm prevention do you use?*When was the last dose given?*Any other questions/comments (anything you want to talk to the doctor about, anything you want us to know, etc.):Sick VisitPet's Name*Is your pet on any medications (supplements, pain meds, etc.)?* Yes NoPlease list them, including dosage and frequency given if possible.*Is your pet on flea/tick prevention?* Yes NoWhat kind? When was the last dose given?*Is your pet on heartworm prevention?* Yes NoWhat kind? When was the last dose given?*What kind of food do you feed?*Is your pet having intestinal issues (vomiting, diarrhea)?* Vomiting Diarrhea NeitherWhat are they vomiting (bile, food, phlegm, etc.)? How often? How long has it been going on? Is there any chance they’ve gotten into anything (trash, houseplants, swallowed toys, etc.)?*How long has it been going on? What consistency is it (very watery vs semi-formed, is there blood/mucous in it, etc.)? Is there any chance they’ve gotten into anything (trash, houseplants, swallowed toys, etc.)?*Is your pet having eye/ear trouble?* Eye trouble Ear trouble NeitherWhen did you first notice the issue? Have you seen any discharge (if so, what color? White, yellow, green?)?Please describe the symptoms (shaking head, scratching, smell, redness, etc.). How long has it been going on? Have you applied any medications, cleaners, or OTC products to the ear(s)?*Is your pet having joint/mobility problems?* Yes NoAre they having pain in a specific part of the body (leg, paw, back, neck, etc.)? If unknown, please say unknown. Are they currently on any joint supplements or pain meds? When did you first notice the symptoms? Are you aware of anything they could have done to cause injury?*Any other symptoms? If so, please describe the symptoms in as much detail as you can. How long have symptoms been present?Any other questions/comments/things you want us to know?CAPTCHAΔ
