Patient History Questionnaire

Pet and Owner Information

Client Name: *

Pet Name: *

Reason for Visit

Heartworm Pretentative

Flea/Tick Pretentative

Last Dewormer Given

Date Dewormer Given

If bloodwork or appointments were performed by another veterinary clinic, which clinic do we contact for records?

Pet's Travel in the past year

Pet's Travel in the next year

What do you feed your pet in a day? Food/Treat | Form (Dry/Wet/Raw) | Amount | Times Per Day | Fed Since

If you feed raw, are there small children or immunocompromised individuals in the household?YesNo

What size measuring device do you use?

Do you give any dietary supplements to your pet? (vitamins, glucosamine, fatty acids, probiotics, etc.)YesNo

If yes, please list brands and amounts:

Is your pet on any medications? Please list all current medications and include dose and frequency.

Any problems or questions for the doctor?