Patient History Questionnaire

Pet Name: *

Client Name: *

Reason for Visit

4DX Test – Heartworm/Lyme/Ehrlichia/AnaplasmosisYesNoDeclined

Heartworm Pretentative

Flea/Tick Pretentative

Fecal SampleYes, I will send to Lab and call tomorrow if positiveNo, Would you like us to obtain one today while you are here?Fecal up to dateDeclined

Preventative Care BloodworkYesUp to DateDeclined

Diet & Amount Being Fed

Treats/Supplements Given

Any problems or questions for the Dr?

Has your pet ever had a vaccine reaction?YesNo

Any coughing or sneezing?YesNo

Any vomiting or diarrhea?YesNo

Any change in appetite or thirst?YesNo

Any change in urination frequency or accidents in the house?YesNo

Any observed lumps/bumps?YesNo

Any observed soreness, stiffness, limping, or difficulty getting up after resting or exercise?YesNo

Any observed change in weight?YesNo

Any signs of allergies (scratching at ears or skin, licking paws, hair loss, rash, etc.)?YesNo

Any change in activity level, energy, or behavior?YesNo

Any dental concerns (bad breath, tartar buildup, difficulty chewing, dropping food)?YesNo

Any eye concerns (redness, discharge, cloudiness, vision changes)?YesNo

Any ear concerns (head shaking, odor, discharge, frequent infections)?YesNo

Has your pet traveled outside the area in the past year?YesNo

Does your pet board, attend daycare, visit dog parks, go hunting, hiking, or swim regularly?YesNo

Is your pet allergic to any medications? If yes, enter medication(s):NoYes, enter medications(s)

Any medications currently taking and dosages? If yes, enter all medications:NoYes, enter medications(s)

Is your pet receiving any supplements? If yes, list:NoYes, List all supplements

For senior pets: Any signs of confusion, nighttime restlessness, hearing loss, vision changes, or house-soiling? If yes, describe:NoYes, Describe

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