Pet Health History - Welcome New Clients! North County Animal Hospital 98642

Date*
MM slash DD slash YYYY
Owner Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Are you bringing your pet in for one of the following? Please select one:*
- New Puppy or Kitten
- Coughing
- Vomiting and/or Diarrhea
- Limping
- Lump
- Skin & Ears
- Urinary Issue
- Reptile or Turtle
- Small Mammal/Pocket Pet
- General Wellness/Other
New Puppy/kitten
Patient Name*
Species
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Weight*
Allergies*
Indoor/Outdoor/Both?*
Free access to outside?*
- Yes
- No
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
HW prevention?*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
Shelter/rescue/private party?*
- Yes
- No
Date*
MM slash DD slash YYYY
Has pet had any training (ex: crate, puppy classes?)*
- Yes
- No
Please explain*
Are you interested?*
- Yes
- No
Are you planning to spay/neuter?*
- Yes
- No
Are you interested in pet insurance?*
- Yes
- No
Do you have any behavior concerns?*
Is your pet on any prescribed or OTC meds?*
- Yes
- No
Please list meds:*
Is there any previous history from organization or owner? (vaccine, deworming, etc.)
- Yes
- No
Please explain*
Has your pet been dewormed?*
- Yes
- No
Has your pet been receiving flea/heartworm prevention?*
- Yes
- No
Do you plan to spay or neuter your pet?*
- Yes
- No
Vomiting and/or Diarrhea
Patient Name*
Species
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Weight*
Allergies*
Indoor/Outdoor/Both?*
Free access to outside?*
- Yes
- No
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
HW prevention?*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
Has pet recently switched food?*
- Yes
- No
Previous brand?*
If yes, how long ago?*
Opened a new bag of food?*
- Yes
- No
Any new treats/table food?*
- Yes
- No
If yes, how long ago?*
How much?*
Is pet Eating/Drinking normally?*
- Yes
- No
If no, explain*
Is pet vomiting?*
- Yes
- No
If yes, for how long?*
How often?*
Keeping water down?*
- Yes
- No
Is pet having diarrhea?*
- Yes
- No
If yes, for how long?*
How often?*
Consistency*
Frequency*
Any new plants around the home?*
- Yes
- No
If yes, list plants*
Any exposure to toxins, garbage, basement, rodent baits?*
- Yes
- No
If yes, please list*
Does pet chew on foreign objects? (toys, socks, rope, etc)*
- Yes
- No
If yes, please list*
Has pet been around any other animals with these symptoms?*
- Yes
- No
If yes, when?*
Has pet been acting lethargic?*
- Yes
- No
If yes, when did symptom first start?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
Please list medications*
Any additional info provided*
Coughing
Patient Name*
Species*
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Allergies*
Indoor Pet /Outdoor Pet/Both?*
Free access to outdoors?*
- Yes
- No
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose*
Heartworm prevention?*
- Yes
- No
Last dose*
Brand of food? How much? How often?*
Is your pet Eating, Drinking, Urinating, Defecating normally?*
- Yes
- No
Please explain*
Any Sneezing, Coughing, Vomiting, or Diarrhea?*
- Yes
- No
Please explain:*
How long has pet been coughing?*
Is it productive?*
- Yes
- No
Has pet had any nasal/ocular discharge?*
- Yes
- No
What is the color of the discharge?*
For how long?*
Has pet been around any other animals with these symptoms?*
- Yes
- No
how long ago?*
Has pet recently been boarded?*
- Yes
- No
when?*
Is pet exercise intolerant?*
- Yes
- No
what type of exercise?*
Does this tend to occur at any certain time of day?*
- Yes
- No
when?*
Any exposure to toxins, garbage, basement, rodent baits?*
- Yes
- No
If so, list*
Does pet chew on foreign objects? (sticks, grass, garbage, etc)*
- Yes
- No
If so, list*
Has pet been acting lethargic?*
- Yes
- No
When did symptom first start?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
Please list the medications:*
When did symptom first start?*
Any additional info:
Limping check-in
Patient Name*
Species*
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Allergies*
Weight*
Indoor/Outdoor/Both?*
Free access to outdoors?*
- Yes
- No
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Is your pet Eating, Drinking, Urinating, Defecating normally?*
- Yes
- No
Please explain*
Any Sneezing, Coughing, Vomiting, or Diarrhea?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
Heartworm Prevention?*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
Is pet limping?*
- Yes
- No
If yes, for how long?*
Which limb?*
Any known trauma?*
- Yes
- No
If yes, what type of trauma?*
When did it occur?*
Has the limping improved or worsened?*
More than one limb?*
- Yes
- No
Has pet had any exposure to ticks?*
- Yes
- No
Have you removed any ticks?*
- Yes
- No
If yes, when?*
Is pet acting otherwise normal?*
- Yes
- No
If no, what other symptoms?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
If yes, list meds*
Any additional info?
Lump
Patient name*
Species*
- Dog
- Cat
Breed*
Sex*
Color*
Weight*
Indoor/Outdoor/Both?*
Free access to outdoors?*
- Yes
- No
Allergies*
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Is your pet Eating, Drinking, Urinating, Defecating normally?*
- Yes
- No
Please explain*
Any Sneezing, Coughing, Vomiting, or Diarrhea?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
Heartworm prevention?*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
When was the lump noticed?*
Has it increased in size?*
- Yes
- No
If so, by how much?*
Is it bothering the pet?*
- Yes
- No
Where is it located?*
Single or multiple masses?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
If yes, list meds*
Does your pet have any chronic conditions?*
- Yes
- No
Please list*
Skin & Ears
Patient name*
Species*
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Weight*
Allergies*
Indoor/Outdoor/Both?*
Free access to outdoors?*
- Yes
- No
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
Heartworm prevention*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
How itchy is pet on a scale 1 -10?*
How long has this been going on?*
Have areas changed on the body?*
- Yes
- No
If yes, how so?*
Has this happened before?*
- Yes
- No
If yes, when?*
Year round or seasonal?*
Is pet scratching ears?*
- Yes
- No
Does pet have a head tilt?*
- Yes
- No
Is pet acting otherwise normal?*
- Yes
- No
If no, what other symptoms?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
If yes, list meds*
Any additional info?
Urinary Issue
Patient Name*
Species*
- Yes
- No
Sex*
Age*
Color*
Weight*
Indoor/Outdoor/Both?*
Free access to outdoors?*
- Yes
- No
Allergies*
Do you have any concerns regarding pet’s Ears/Eyes/Nose/Skin/Mouth?*
- Yes
- No
Please explain*
Flea treatment?*
- Yes
- No
Last dose?*
Heartworm prevention?*
- Yes
- No
Last dose?*
Brand of food? How much? How often?*
When did the urinary issue start?*
Drinking a lot?*
- Yes
- No
Is there blood present?*
- Yes
- No
Increased urination?*
- Yes
- No
If so, how much?*
Accidents in the house?*
- Yes
- No
Normal stream?*
- Yes
- No
Is pet squatting or lifting leg to urinate?*
Small/frequent amounts?*
Have you given any medications either prescribed or OTC?*
- Yes
- No
If yes, list meds*
Does your pet have any chronic conditions?*
- Yes
- No
Please list:*
Reptile or Turtle
Pet's name*
Type of Enclosure/Flooring*
Furnishings?*
Heat source? (heat,light,UV light)*
Temperature/Humidity levels?*
How is the temperature and humidity being measured?*
Eating/Drinking/Urinating/Defecating well?*
- Yes
- No
Please explain*
Select any of the following symptoms:*
- Vomiting
- Diarrhea
- Sneezing
- Coughing
- None
Food brand/Commercial?*
Are you raising reptile’s own food?*
Food gut loaded or dusted on food?*
Are you giving any vitamin supplements?*
- Yes
- No
What are the supplements?*
How often are you giving the supplements?*
What is the Calcium:Phosphorus ratio?*
How often are you feeding?*
What percent of cage is water? (Turtle only)*
Type of filtration system is used? (Turtle only)*
Are you measuring water temp? (Turtle only)*
Is water offered?*
- Yes
- No
How is it offered?
How often is the enclosure cleaned?*
What is it cleaned with?*
Any chronic conditions?*
- Yes
- No
Please list:*
Any current medications?*
- Yes
- No
Please list:*
Small Mammal/Pocket Pet
Pet's name*
Provide information about your pet’s cage:*
Location in home*
Furnishings present*
- Yes
- No
Type of Flooring*
How often is the cage cleaned?*
What kind of bedding/litter do you use?*
How often is the bedding changed?*
Does your pet exercise?*
- Yes
- No
What type of exercise and at what frequency?*
Any Recent Changes?*
Is pet Eating/Drinking/Urinating/Defecating well?*
- Yes
- No
Please explain*
Select any of the following your pet is experiencing:*
- Vomiting (Ferrets)
- Diarrhea
- Coughing
- Sneezing
- None
Brand of Food?*
If feeding fresh fruits/veggies and pelleted food, what percentage of each does the diet consist of?*
How much?*
How often?*
Are you giving any supplements (Treats and Vitamins)?*
- Yes
- No
Please list supplements:*
How are you offering water?*
How often is the water container cleaned?*
Any chronic conditions?*
Any current medications?*
General Wellness/Other
Patient Name*
Species*
- Dog
- Cat
Breed*
Sex*
Age*
Color*
Reason for visit*
Allergies*
Chronic Conditions*
Is your pet Eating, Drinking, Urinating, Defecating normally?*
- Yes
- No
If No, Please explain*
Any Vomiting/Diarrhea/Sneezing/Coughing?*
- Yes
- No
If Yes, Please explain*
Any problems with Ears/Eyes/Nose/Skin/Mobility/Mouth?*
- Yes
- No
If Yes, Please explain*
Indoor Pet/Outdoor Pet/Both?*
Brand of food?*
How much?*
How often?*
Is your pet on any prescriptions/supplements?*
- Yes
- No
If so, what prescriptions/supplements.*
Is your pet on flea/heartworm prevention?*
- Yes
- No
If so, what brand?*
When was it given last?*
CAPTCHA

Pet History Check-In Form

New Puppy/kitten

Vomiting and/or Diarrhea

Coughing

Limping check-in

Lump

Skin & Ears

Urinary Issue

Reptile or Turtle

Small Mammal/Pocket Pet

General Wellness/Other

Make an appointment
with us today!

New Puppy/kitten

Vomiting and/or Diarrhea

Coughing

Limping check-in

Lump

Skin & Ears

Urinary Issue

Reptile or Turtle

Small Mammal/Pocket Pet

General Wellness/Other

Make an appointmentwith us today!

Make an appointment
with us today!