Patient History Form

Clinic: 807 9th St. Golden, CO
Mail: 815 9th St. Golden, CO 80401
Barbara Goodrich, DVM, Director [email protected]
Celeste Abell, DVM, Associate
William Simpson, Business Manager
New Patient's Medical History Form
Owner/caretaker: ________________
Today's date: ___________
Your best contact phone: ____________________ Alternate phone number(s): _______________
Email address:____________________
Would you like to be on our email list, or not? Yes ☐
No ☐
Patient: _____________
Age: _________
Sex & reproductive status: Female intact ☐
Female spayed ☐
Male intact ☐
Male neutered ☐
Breed of cat (if known): _______________
The cat's usual personality (outgoing, cuddly, shy, energetic, mellow, leader, prankster, whatever terms fit):
___________________________________________ Has this changed recently, and if so, how? ____________________
Chief complaint(s) for this visit: ____________________________
Duration of the problem(s), hours, days, weeks: ____________________________
Has the problem become worse quickly or slowly, stayed about the same, or waxed and waned? ________________
Any current treatment for this problem, and if so, has it helped? _________________
Any prior treatment for this problem, and if so, has it helped? _________________
Any current or prior diagnostic tests for this problem, and if so, what was found? _______________________
Is the patient's appetite normal ☐, decreased ☐, or increased ☐?
Is the patient's weight stable ☐, decreasing ☐, or increasing ☐?
Is there any vomiting, and if so, how often and when? ____________
Is the patient's water intake normal ☐, decreased ☐, or increased ☐?
Is the patient straining to eliminate? No, that appears normal ☐. Yes, straining to eliminate ☐.
Is the patient's urination normal amount ☐, decreased ☐, or increased ☐? Is there any blood in the urine? ☐
Is there any diarrhea, and if so, how often and what texture is it (slightly loose, liquid, mucousy, etc.)? __________
Is the patient urinating and defecating only in the litter-box? If not, where and when?________
Is the patient's activity level normal ☐, decreased ☐, or increased ☐?
Is there any recent change in behavior or attitude, for example, increased irritability, or lethargy? If so, what? ___
Have there been any changes in the household recently, for example, moving house, a change of diet, a new resident? ___
Is there any weakness, lameness, or noticeable pain
in any limbs or other region? If so, what? _________
Is the patient having problems with one or more specific
parts of his/her body? Are there any injuries, new lumps, or
other problems? If so, please mark on the diagram here:
General background
Is the patient currently taking any medications or supplements, including nutraceuticals, topical meds, ear meds, eyedrops,
nutraceuticals, or insecticides? If so, what are they, at what dose, and how often?
Dose & frequency:
What it is treating:
Side effects/concerns?
When were the patient's last Rabies and FVR-CP vaccines given, if known? ___
(FVR-CP: Feline Viral Rhinotracheitis a.k.a. Feline Herpesvirus-1, plus Calicivirus plus Panleukopenia virus)
Do you want the patient to get a FeLV (Feline Leukemia virus) vaccine? ___
Has the patient ever had a bad reaction to a vaccine? No ☐.
Yes ☐. Details: ___
What does the patient eat, including treats, table-scraps, and so on? Have there been recent changes?___
Is the food fed at mealtimes, or left in a bowl for free-feeding? Meals ☐. Free-feeding ☐.
Has the patient ever travelled outside Colorado? If so, where and when? ___
How many other cats or other animals are in the household? ___
Are any of the cats allowed outside, and if so, what is the environment like? ___
(Rural area with barns, wooded area with wildlife, suburban neighborhood, etc.)
Does the household include any children? ☐ Expectant mothers? ☐ Elderly or immunosuppressed people? ☐
Previous Medical History
Has the patient had any previous surgeries or procedures involving anesthesia? If so, what and when? ___
Were there any complications, including complications from the anesthesia? ___
Has the patient ever had a bad reaction to any medication? ___
Has the patient had any other problems, and if so, when, how were they treated, and are they continuing or resolved?
General: _______________________
Skin: __________________________
Head/Neck: __________________________
Eyes-Ears-Nose-Throat: __________________________
Respiratory: __________________________
Cardiovascular: __________________________
Hemolymphatic (for example, anemia): __________________________
GI, Digestive: _________________________
Urinary: __________________________
Reproductive: __________________________
Mammary: __________________________
Musculoskeletal: __________________________
Neurologic: __________________________
Behavioral: __________________________
Other: __________________________
Is there anything else you'd like to mention or ask about? __________
Complimentary optional services
Would you like a nutritional and/or ideal body weight assessment?___________________
Would you like information about pet insurance?___________________