Patient Health History Form – Long Drive Dog and Cat Hospital

Thank you for taking the time to complete the form below prior to your pet’s appointment. We look forward to seeing you and your pet soon!

Pet Owner’s Name*

First Last

Phone Number*

Email*

Patient Name*

Pet Breed

Pet Age/Date of Birth

Date*

Is your pet eating and drinking normally?*

Yes
No

Please describe symptoms and duration:*

What diet is your pet currently on?*

Has your pet been experiencing vomiting or diarrhea?*

Yes
No

Please describe symptoms and duration:*

Is your pet coughing or sneezing?*

Yes
No

Please describe symptoms and duration:*

Is your pet currently taking a flea/tick preventative?*

Yes
No

Please list the product name and frequency given:*

Is your pet currently taking a heartworm preventative?*

Yes
No

Please list the product name and frequency given:*

Is your pet currently taking prescription medication(s)?*

Yes
No

Please list the medication name(s), frequency given, and prescriber’s name:*

Please list the condition for which your pet’s medication was prescribed:*

Do you need medication refills?*

Yes
No

Please list the medication name(s), frequency given, and prescriber’s name:*

Does your pet have anxiety?*

Yes
No

Please describe symptoms and activities surrounding anxiety episodes:*

Have you noticed your pet behaving abnormally recently?*

Yes
No

Please describe symptoms and duration:*

Does your pet spend time scratching/licking/chewing their skin/fur?*

Yes
No

Please describe symptoms and duration:*

Does your pet experience stiffness/soreness?*

Yes
No

Please describe symptoms and duration:*

Have you noticed any new lumps or growths on your pet?*

Yes
No

Please describe describe the location and when the change was first noticed:*

What is your pet’s typical environment (i.e. stays at home, visits local dog parks/attractions, travels frequently)?*

Are you planning to board your pet in the near future?*

Yes
No

Please list upcoming boarding dates and facility:*

Has your pet stayed at a boarding facility since your last visit?*

Yes
No

Please list most recent boarding dates and facility:*

Please list any additional health history you’d like to share:*