New Patient History

Pet Name

Client First Name

Phone

Client Last Name

Email

Reason For Visit

Vaccinations Current

Yes

No

Flea & Tick Preventative, Heartworm Preventative

Appetite

Normal

Abnormal

If abnormal, please describe:

Water intake:

Normal

Abnormal

Ears:

Normal

Abnormal

If abnormal, please describe:

Behavior:

Normal

Abnormal

If abnormal, please describe:

Nasal Discharge:

Yes

No

Pet's Birthday

If yes, please describe:

Weight:

Loss

Gain

No Change

Please any describe recent weight change:

Stool:

Normal

Abnormal

If yes, please describe:

Eyes:

Normal

Abnormal

If abnormal, please describe:

Recent Travel

Yes

No

Urination:

Normal

Abnormal

Vomiting:

Yes

No

If abnormal, please describe:

Respiratory Symptoms:

Normal

Coughing

Sneezing

Wheezing

Parasite Prophylaxis

No

Yes

If abnormal, please describe:

Please list all of your pet's medical conditions:

Please list any known allergies:

Please list past surgical/medical procedures:

What food is your pet regularly fed? (brand, amount, frequency)

Where did you get your pet and at what age?

Environment

Please list all of your pet's medications including over-the-counter, vitamins, supplements, herbs: [Medication Name, Prescribed By, Dosage (MGs/Units), When is medication given (AM/PM), Frequency (# of times given per day)]

If needed, please provide any additional comments regarding your pet's visit:

Additional companion animals

Yuri A Lawrence, DVM, Ph.D, MA, MS, DIPL.ACVIM(SAIM)

New Patient Questionnaire

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