New Patient History Form Name First Last AnimalAgeDate Date Format: MM slash DD slash YYYY AddressCityStateZip codeEmailPhoneCell PhoneBusiness-PhoneThese questions are very important in order for us to keep up with, and better understand your pet’s medical history. Thank you for helping us care for your special family member. Please make any necessary changes to your information above, just cross out and correct. General HistoryAre your pet’s vaccinations up to date?YesNoDate of last vaccinationsDo you have pet insurance?YesNoIs your pet spayed or neutered?YesNoDoes your pet have a microchip?YesNoIs your pet on Heartworm Prevention?YesNoHas your pet been heartworm or Feline Leukemia/FIV tested in the last year?YesNoHas your pet been tested for intestinal parasites in the last year?YesNoAre there other animals in the household? Please list:How long have you owned your pet?Did your pet eat in the last 12 hours?YesNoPast HistoryHave there been any significant surgeries, injuries or illnesses in your pet’s past? If yes, please relate the diagnosisIf sick, has your pet been treated for this problem before? If so, when?What treatments have you given for the problem? Type and DosageAre any other animals in the household sick?Please describe the problem, how long it has been going on, and how it progressedWhat diet do you feed?CannedDryBothHow much daily?Have you changed diets recently?YesNoWhat treats do you give?How many daily?Table Food?YesNoIs your pet’s appetite:ABSENTDECREASEDNORMALINCREASEDUNKNOWNIs your pet currently taking any prescriptions medications? Please list:Is your pet taking any over-the-counter or home herbal remedies?YesNoPlease specifyRelative to normal, is your pet’s activity:DECREASEDNORMALINCREASEDWhat type of heartworm & flea/tick control do you use?Refills needed?Is your pet allergic to any food or medications?To vaccines?
