Pre-Exam Patient Medical History Form Pre-Exam Patient Medical History Form Please complete the pre-exam medical history form to help our Veterinarians give your pet the best care possible. Name (Primary Guardian and Contact)* First Last Pronouns Ex: She/Her, He/Him, They/ThemEmail*Our hospital uses email as a primary form of communication. If you wish to not provide an email address please type none@email.com Enter Email Confirm Email Primary Phone*May the Dr. and nursing team text you at the phone number provided?* Yes No We only utilize texting to communicate important information regarding your pet's medical care. May we utilize pictures of your pet(s) in our social media posts (e.g. Instagram, Twitter, Facebook)?* Yes No Please tell us about your pet that has the scheduled exam.Pet's Name* Name Species* Cat Dog Pet's Sex*MaleMale NeuteredFemaleFemale SpayedPlease list current diet and amount fed daily.* Any Known Vaccine or Medication Allergies?*Type none if no known allergies or reactions.Please List All Current Medications and Supplements:*Include any medications or supplements to help with fear, anxiety, or stress at the veterinary hospital. List current dose level, frequency of administration, and when last given. Type none if no current medications or supplements.How would you describe your pet's reaction to going to the veterinary hospital?*Eager and ExcitedSubduedReluctantSomewhere in betweenHas your pet shown avoidance or dislike of any of the following? Select All Getting into the carrier or the car Entering the veterinary hospital Other pets or people passing by while in the lobby Being approached by veterinary staff Getting on the scale for a weight Hearing phones ringing or doorbells Going into the exam room Being lifted onto the exam table (for small animals only) Loud voices during examinations Having a rectal temperature taken The use of instruments such as stethoscope or otoscope (to look into the ears) Sounds coming from the back areas of the practice Being taken out of the exam room for procedures Having certain parts of their body handled (such as face, ears, paws, belly etc) You can add additional comments below.Use this area to expand on your pet's veterinary experiences, if needed:What are your pet's favorite treats? Please bring some of these to your next visit to our hospital. List allergies, if any.Choose primary reason for today's visit.*Healthy Adult Pet Wellness ExamMedical/Behavioral ConcernSenior Pet Twice Yearly ExamPuppy/Kitten ExamRecheck ExamMedical/Behavioral ExamCurrent Flea and Parasite Prevention Used?*Select all flea and parasite prevention medications that have been used in last 3 months. Cheristin Credelio Credelio Cat Interceptor Plus Revolution Plus Simparica Trio None Other Choose all symptoms that apply to your pet's medical exam visit.*Choose all symptoms that you have noted in your pet that relate to today's visit. Appetite Decreased Appetite Increased Behavioral Problem Blood In Stool Breathing Difficulty Constipation Coughing Dental Problem Diarrhea Drinking Increased Ear Inflammation/Discharge/Odor Eye Inflammation/Discharge Fever Fleas Noted Hairballs Hearing Loss Lethargy Limping Lump/Mass Noted Muscle Weakness/Wasting Nail Concern Painful Parasite Scratching Scooting Seizure Skin Inflammation/Scabbing Sneezing/Nasal Discharge Urinary Incontinence Urination Difficulty/Straining Urine Bloody Urine Output Increased Vision Loss Vomiting/Regurgitating Weight Gain Weight Loss Other Concern Please provide details on "Other Concern"*Be as detailed as possible to help the Veterinarian understand your concerns.Tell us about the decreased appetite.*Provide us details on the decreased appetite. How long has this been going on? Any changes to diet or household?Tell us about the increased appetite.*Provide us details on the increased appetite. How long has this been going on? Any changes to diet or household?Tell us about the behavioral problems.*Be as detailed as possible regarding all behavioral problems. When did they start? Getting worse or better? Changes to household?Tell us about the blood in stool.*How long has blood appeared in stool? Is blood red or dark in color? Does it appear with every bowel movement?Tell us about the breathing difficulty.*How long has the breathing difficulty been going on? Does it occur all the time or just after exercise? Do you notice a change in gum color (bluish)? Is there a cough noted as well?Tell us about the constipation.*How long has the constipation been going on? Is the problem improving, worsening or staying the same? When the stool is passed is it hard, soft, normal consistency? Is the volume of stool passed small, normal, or bulky? Blood noted in stool?Tell us about the coughing.*How long has the coughing been going on? Intermittent or occurs regularly? Dry or productive cough? Does coughing worsen with exercise?Tell us about the dental problem.*How long has the dental problem been a concern? Bad breath? Inflamed or red gums? Excessive drooling? Teeth missing or broken? Difficulty chewing or pain noted? Bloody saliva?Tell us about the diarrhea.*How long has the diarrhea been going on? Is the stool semi-formed or all liquid? How many times per day? Is volume of stool small, normal or large? Blood present in stool? Is the diarrhea improving or worsening? Any diet or household changes? Has a fecal analysis been performed recently? Tell us about the increased drinking.*How long has the increased drinking been going on? Is this a daily occurrence or intermittent? Tell us about the ear problems.*How long has the ear problem been going on? Which ear is affected? Is it improving, worsening or staying the same? Has this problem occurred before? Is there discharge? Is there a foul odor? Is your pet scratching at the ears?Tell us about the eye problems.*How long has the eye problem been going on? Which eye is affected? Is it improving, worsening or staying the same? Has this problem occurred before? Is there discharge, redness, swelling? Tell us about the fever.*How long has the fever been going on? How did you assess your pet for a fever? Tell us about the fleas.*How long have fleas been a problem? Are all pets in the household using flea prevention? Has your house or apartment been treated for fleas? How many consecutive months have you treated your pet for fleas?Tell us about the hairballs.*How long have hairballs been a problem? How often do they occur? Is it just hair or is there regurgitated food as well? Is your pet routinely brushed? Are you currently using a hairball remedy?Tell us about the hearing loss.*How long has the hearing loss been a problem? Has the problem presented spontaneously or gradually over time? Describe what you experience that suggests hearing loss.Tell us about the lethargy.*How long has lethargy been a problem? Is the lethargy continuous or intermittent? Any other symptoms that accompany the lethargy?Tell us about the limping.*How long has limping been a problem? Which limb(s) are affected? Is the limping the result of a known injury? Is the limping intermittent or continual? Does the affected limb change over time?Tell us about the lump/mass.*Where is(are) the mass(es) located? How long ago did the mass appear? Is the mass changing in size or shape? Has your pet had previous removal of any masses?Tell us about the muscle weakness/wasting.*How long has muscle weakness/wasting been a problem? Is the problem localized to a few muscles or the entire body?Tell us about the nail concern.*Which nail(s) are affected? Is the nail torn or bleeding? Is there inflammation or discharge from nail bed? Was there a known injury that caused the current nail concern? How long has this problem been going on?Tell us about the pain your pet is experiencing.*Where is the pain located? How long has your pet been painful? Is the pain continuous or intermittent? Was there an injury associate with the pain? Is the pain affecting your pets overall quality of life and normal routine?Tell us about the parasites you are concerned with.*Are you noticing worms in the stool? Are ticks a concern with your pet? What is the appearance of the parasites? Do you have small children in your household? Has your pet been dewormed in the last 6 months?Tell us about the scratching.*How long has the scratching been a problem? Is there a specific area your pet scratches? Is the scratching improving, worsening or staying the same? Has your pet had scratching problems in the past?Tell us about the scooting.*How long has scooting been a problem? Has your pet had past problems with anal glands? Has your pet received a fecal analysis or deworming in the last 6 months? Does your pet also lick at the anal region?Tell us about the seizures.*Is this your pet's first seizure? How frequent are the seizures? How long does an episode last? Describe what your pet's seizure looks like?Tell us about the skin inflammation/scabbing.*Is the problem localized or present over entire skin? Is your pet scratching? How long has the problem been going on? Is there a noticeable odor? Has your pet had skin problems before? Has there been any change to the diet, shampoos used or topical medications?Tell us about the sneezing/nasal discharge.*How long has the sneezing/nasal discharge been going on? How frequent is the problem? Is the sneezing/nasal discharge improving, worsening, or staying the same? Is the nasal discharge clear or colored? Tell us about the straining/difficulty urinating.*How long has the urinary straining/difficulty been going on? How often does your pet urinate per day? Is your pet capable of producing any urine when straining? Is there any blood in urine? Does your pet seem painful when trying to urinate?Tell us about the urinary incontinence.*How long has the urinary incontinence been going on? Is the incontinence worsening, improving, or staying the same?Tell us about the bloody urine.*How long has the blood been present in the urine? Is your pet urinating more frequently? Has there been any changes in your household?Tell us about the increased urine output.*How long has the increased urination been going on? Is the urine bloody? Are you noting a marked increase in water intake?Tell us about the vision loss.*How long has the vision loss been going on? Has the loss been gradual or abrupt? Tell us about the weight gain.*Has the weight gain been gradual or abrupt? Is the food you feed your pet measured or free fed? Have you recently changed diets? Tell us about the weight loss.*Has the weight loss been gradual or abrupt? Is the food you feed your pet measured or free fed? Have you recently changed diets? Please list any additional items you wish to discuss with the Veterinarian during the visit.Adult Wellness ExamCurrent Flea and Parasite Prevention Used?*Select all flea and parasite prevention medications that have been used in last 3 months. Cheristin Credelio Credelio Cat Interceptor Plus Revolution Plus Simparica Trio None Other Please list any concerns or specific items you wish to discuss with the Veterinarian during the visit.*Puppy/Kitten ExamCurrent Flea and Parasite Prevention Used?*Select all flea and parasite prevention medications that have been used in last 3 months. Cheristin Credelio Credelio Cat Interceptor Plus Revolution Plus Simparica Trio None Other Please list any concerns or specific items you wish to discuss with the Veterinarian during the visit.*Recheck ExamDetail the reason for recheck exam and any items you wish to discuss with the Veterinarian during the exam.*Please indicate the overall progress of your pet.*ImprovedWorseNo changeSenior Pet Twice Yearly ExamCurrent Flea and Parasite Prevention Used?*Select all flea and parasite prevention medications that have been used in last 3 months. Cheristin Credelio Credelio Cat Interceptor Plus Revolution Plus Simparica Trio None Other Please select any changes you have noted in your pet. Appetite Decreased Appetite Increased Drinking Increased Lethargy Hearing Loss Mobility Reduction Urinary Incontinence Urination Increased Volume Vision Loss Weight Gain Weight Loss Please list primary concerns or items you wish to discuss with the Veterinarian during the scheduled exam..*NameThis field is for validation purposes and should be left unchanged.
