Patient History Form Patient First Name: Patient Last Name: Presenting complaint:How long has the problem been going on/when did the problem start?:How is your pet's energy level? Describe your pet's urination (amount/frequency/color): When was your pet's last urination? Describe your pet's defecation (how often/color/consistency): When did your pet last defecate? Is your pet vomiting? Yes No How often? When was last vomiting episode? What does the vomit look like? What does your pet eat (please describe all food and treats)? When was the last time your pet ate? Please describe your pet's appetite: Does your pet have any pre-existing medical conditions? Yes No If so, please describe:Please list all of the medications your pet is on (including heartworm/flea/tick preventative:Drug 1/Dose/Frequency Drug 2/Dose/Frequency Drug 3/Dose/Frequency Drug 4/Dose/Frequency Drug 5/Dose/Frequency Is your pet Indoors Outdoors Both Are your pet's vaccines up to date (including rabies)? Yes No Does your pet live with other animals or has your pet been exposed to other animals recently? Yes No If so, please list the other animals: Has your pet been exposed to toxins, household medicines, or cleaning supplies? Yes No If so, what?: Are there any other conditions that your pet has that has not been answered by the previous questions? Yes No If so, please describe:Last healthy vet check up:
