Patient History Form

Pet Name*

Exam Date*

Why is your pet coming to see us?
*Check all that apply**

Cat - Annual Wellness

Dog - Annual Wellness

Illness Check-Up

What food are you currently feeding your pet?
*Check all that apply**

Dry Food

Wet Food

Treats/Snacks

What brand of food are you feeding your pet?*

How much food is your pet given daily approximately?*

Does your pet have chew toys?*

Yes

No

Has your pet been eating normally?*

Yes

No

How many treats is your pet given daily approximately?*

How is your pet's water consumption?*

Normal

Increased

Decreased

Is your pet on heartworm preventatives?*

Yes

No

Is your pet on flea/tick preventatives*

Yes

No

Is your pet on any other medications?*

Yes

No

Is your pet on any supplements?*

Yes

No

Has your pet had any coughing?*

Yes

No

Has your pet had any sneezing?*

Yes

No

Has your pet had any diarrhea?*

Yes

No

How many minutes of exercise is your pet getting per day?*

None

15 - 30 minutes

30 - 60 minutes

Over 60 minutes

How is your pet's energy level?*

Poor