Central Animal Hospital

 

Central Animal Hospital

Form - Patient History Questionnaire

Name (required)
First Name (required)
Last Name (required)
Contact Number (required)
Phone TypePhone Number (required)
Any changes to your address or telephone number? Please list below.

Patient Information
Pet's Name (required)

Is your pet currently on any medications?
Yes
No
If yes, please enter medications below.

Does your pet have any known allergies?
Yes
No
If yes, please list them below.

What brand of food do you currently feed?
Brand of Food

What type of food are you currently feeding?
Wet (Canned/Foil Wrapped)
Dry (Kibble)
Both Wet and Dry
Approximately how much food does your pet eat daily?
Please Note:
Select only one of the below options. Also, one cup of food is equal to 8oz
< 1 cup
1 - 2 cups
2 - 3 cups
3 - 4 cups
4 - 5 cups
> 5 cups
Free/Self Fed
Do you brush your pet's teeth or use other plaque preventatives?
Brush
Treats
Oral Rise
OraVet
Other
If other please note:

None
For Cats: What percentage of time does you cat spend outdoors?
Select only one: :
If your cat spends time outside, is he/she supervised?
Yes
No
Has your pet had any injury or illness in the past 30 days?
Yes
No
If yes, please list the nature of the injury and how long ago it happened.

Does your pet have any history of seizures?
Yes
No
If yes, please explain the frequency and whether or not you keep a seizure log.

Has your pet shown any recent changes in the following:
If you select yes, please give a brief explanation and note when these changes started.
1.) Appetite or Water Intake:
No
Yes
Explanation: (Appetite or Water Intake)

2.) Bowel Movements or Urination:
No
Yes
Explanation: (Bowel Movements or Urination)

3.) Weight:
No
Yes
Explanation: (Weight)

4.) Behavior:
No
Yes
Explanation: (Behavior)

Has your pet exhibited any of the following problems:
If you select yes, please notate when these changes started.
1.) Lumps, Bumps, Hair Loss, or Scratching:
No
Yes
Explanation: (Lumps, Bumps, Hair Loss, Scratching)

2.) Coughing, Sneezing, or Vomiting:
No
Yes
Explanation: (Couging, Sneezing, Vomiting)

3.) Shaking Head or Bad Breath:
No
Yes
Explanation: (Shaking Head, Bad Breath)

4.) Weakness, Lameness, Stiffness, or Difficulty Rising:
No
Yes
Explanation: (Weakness, Lameness, Stiffness, Difficulty Rising)

Do you have any other questions or concerns?


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