Client Name * First Name Last Name Patient Name * What are we seeing your pet for today? * Please explain what you are seeing, how often you are seeing it and when it started. Any of the following conditions seen? (Check all that apply) * Coughing Sneezing Vomiting Diarrhea Urinating frequently or large amounts Weight decrease Weight increase Thirst increase Appetite change None of the above What medications/vitamins/supplements is your pet currently taking? * Please include strengths of medications if known and dosages. What heartworm prevention is your pet on currently? * What was the date of the last dose given? Approximate is ok. MM DD YYYY Do you give this prevention every month? * Yes No N/A What flea/tick prevention is your pet on currently? * What was the date of the last dose given? Approximate is ok. MM DD YYYY Do you give this prevention every month? * Yes No N/A List any major medical problems diagnosed in the past. * How is your pet's mobility? (Limping/arthritis/etc) * If abnormal, please explain what you are seeing, how often you are seeing it and when it started. What brand of food do you feed? * Check all that apply * I feed dry I feed canned I give treats I give table/people food How many cups/cans of food do you feed per day? * How many treats/table food do you give your pet per day? (Ex: Peanut butter, cheese, etc) * Sex: Please choose all that apply * This is important to know because some medications can harm developing puppies and cause fertilization issues for breeding pets. My pet is neutered/spayed. My MALE pet is not neutered. My FEMALE pet is not spayed and is not pregnant. My FEMALE pet is not spayed and might be pregnant. I plan on breeding I do not plan on breeding. I take my pet to: (Check all that apply) * Grooming Boarding Daycare Dog parks Obedience classes None of the above Other List other pets that share the household with your pet below. * What number do you want us to contact you back? * We will contact you with any questions. (###) ### #### Additional phone number (###) ### #### Thank you!
