New Patient & History
Owner Information
Primary Contact
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Owner's Name *
Address *
Street Address
Province / Region
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Apt, Suite, Bldg. (optional)
Postal / Zip Code
Country
Primary Phone *
Primary Phone Type *
Home phone
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Primary Email *
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DL#/State
Cell phone
Work phone
Alternate phone
Work phone
Alternate phone
Secondary Contact
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Secondary Name
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Relationship
Secondary Phone:
Secondary Phone Type
Home phone

Cell phone
Secondary Email:
Veterinarian Information
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Primary Care Veterinarian *

Hospital Name *

Preferred Pharmacy
City
State /

Pharmacy Phone
Patient Information
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Patient Name *
Species *
Dog

Age *
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Breed *
Sex *
Cat
Female

Color(s) *
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Allergies *
Environment *
Indoor
Female Spayed
Outdoor
Both
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Length of ownership *
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List diet fed *
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Amount fed and frequency *
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Last meal date and time
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Travel History (lived or visited) *
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List other pets in household *
Additional Notes
Patient History

Reason for visit *
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Previous History
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Duration of problem *
Male
Male Neutered
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Problem is
Getting better

Worse
Same
Medications and Supplements *
List all prescription and over the counter medications and supplements patient is currently receiving.

Name of Flea/Tick Prevention product *
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Name of Heartworm Prevention product *
Any missed doses? *
Yes
No

Length of time between missed doses
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Date of last heartworm test / result
Clinical Signs

Activity Level *
Increased


Decreased
Normal
Decreased
Appetite Change %
Weight *
Increased

Normal
Drinking Change %
Appetite *
Increased


Decreased
Activity Level Change %
Drinking *
Increased


Normal
Normal
Weight Change %
Urination Symptoms
Decreased

Urination *
Increased


Normal
Urination Change %
Urine Changes
Straining

Decreased
Change in odor
Change in color
Urine Color
Vomiting Symptoms

Vomiting *
Yes

Unsure
Blood present?
Yes

No
No
Getting better or worse?
Better
Worse

Vomit Contents

Vomit Frequency

Vomit Color
Bowel Movement Symptoms

Bowel Movement *
Diarrhea

Static
Progressively worse
Stool Changes
Straining

Constipation
Improving or worse?
Improving

Normal
Black/tar color
Bowel Movement Frequency
Respiratory Symptoms
Red/blood seen
Mucus

Breathing Changes *
Fast / Panting

No
Coughing Description
Dry cough

Wet cough
Afternoon
Static
No
Nasal Discharge *
Yes
No

Discharge Color

Discharge Frequency
Bleeding / Bruising Symptoms

Abnormal bleeding/bruising *
Yes

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Non-productive
Bedtime
Progressively worse
Sneezing *
Yes

Evening
When did coughing start?
Coughing is
Improving

Productive
Hack/ followed by gag
Coughing Frequency
Morning

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Labored
Coughing *
Yes

Normal
No
Unsure
Bleeding/Bruising Location
Other Abnormalities
After activity
At rest