Patient History Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Are you currently a client of GACC?NoYesPet's NamePet's SpeciesCanineFelinePet's BreedPet's AgeUnder 1 Year OldBetween 1 and 7 Years Old7 Years or OlderWhere does your pet spend the majority of their time?InsideOutsideBothDoes your cat hunt?NoYesHow is the potty training / litter box training going?Is your pet having issues with their hearing, vision, or movement? If yes, please explain.Has there been a change in diet? What food is being fed and how much/frequency?Is your pet currently taking any parasite preventive (flea, tick, heartworm) medication?NoYesIf yes, please list all preventive medications.Is your pet currently taking any other medications or supplements?NoYesIf yes, please list all supplements and medications.Reason for upcoming visit:Does your pet have any preexisting medical conditions we should know about?NoYesPlease list all medical conditions here.Has your pet traveled recently?NoYesAre there other pets in the household?NoYesPlease list all additional cats, dogs, and other pets.Is your pet in need of a recheck from a previous exam?NoYesIs the initial problem better, worse, or the same?Are you able to give the medication(s) as prescribed?Are you finished with the meds? Any change in appetite or drinking habits during medicating?Any vomiting or diarrhea while on the medication?Has your pet been coughing?NoYesIs it a productive cough, and if yes, what does the pet cough up?Has your pet been recently boarded or around other/new pets?Is there a time of day or situation when the cough is more prominent?Is your pet experiencing eye issues?NoYesDoes there seem to be any pain (ie squinting)?Is the pet rubbing at eye(s) a lot?Any other pets or people affected in the house?Is there a known trauma?Have you tried any medications at home already?Is your pet dealing with ear issues?NoYesAre the ears painful?Do you clean the ears on a regular basis?Is the pet scratching or shaking its head at lot?Have you tried any medications at home?Does your pet have a recent history of swimming, bathing, or a moist environment?Is your pet experiencing diarrhea?NoYesPlease describe (bloody, mucoid, watery, amount, normal color but different consistency):What do you normally feed? Amt and freq?Have there been any recent changes in their diet?Did you recently open a new bag of food?Did you recently purchase a new type of treat/rawhide/bone?Have you tried a bland diet?Is there any history of eating garbage, table food, toys?Has there been a change in environment, boarding or other stress?Have you noticed any lumps?NoYesIf yes, please explain. Are there any behavioral concerns?NoYesIf yes, please explain.Has the pet been able to bear weight normally on all four legs?NoYesWhich leg(s) are affected? Is it a shifting leg lameness?Has it been an acute and rapid onset?Have you noticed any swelling?NoYesHave you seen any blood?NoYesHave you noticed any issues with your pet's mouth, teeth, or gums?NoYesIs there severe odor?NoYesDoes the pet favor one side of the mouth when they eat?NoYesIs there a history of trauma?NoYesIs there any excessive drooling?NoYesDoes the pet paw at its mouth?NoYesHas the pet changed its food preference (i.e. hard/semi-soft/canned)?NoYesDo you have an at-home dental plan you follow?NoYesHave you noticed any issues with your pet's nose or throat?NoYesHas the pet's appetite changed?NoYesAre there any difficulties swallowing?NoYesIs there any sneezing, nasal discharge or bleeding?NoYesIf discharge is present, is it from one or both nostrils?LeftRightBothIs there any time of day or situation where the symptoms are worse?NoYesChanges in sleeping behavior?NoYesPlease describe your pet's change in sleeping behavior.Does your pet have a history of seizures?NoYesHow long has your pet been having seizures?How far apart are they?Are there any obvious triggers? (i.e. storms, people, full moon, medications)How long do they last?Are they getting progressively worse (i.e. more violent)?Does your pet have cluster seizures (multiple seizures in a row)?NoYesDoes your pet swim, urinate and/or defecate during the seizure?NoYesDoes your pet have a history of skin issues?NoYesIs your pet scratching (pruritic?)NoYesIs your pet chewing/licking the lesion or feet/tail?NoYesHave you seen any fleas or other parasites on the pet?NoYesDoes the lesion appear to be spreading or increasing in number?NoYesHave you tried any medication? Please list them here.Is your pet experiencing any issues with urination?NoYesIs your pet unable to urinate or straining with no success?NoYesIs the urine a normal color, amount, and frequency?NoYesAre any of your pet's urination habits different (i.e. out of box, in house)Does your pet have control over urination (or does it happen without them knowing it)?Has your pet been vomiting? NoYesIs there a particular time of day/night it occurs?Did you recently open a new bag of food?NoYesDid you recently buy new treats/rawhides/bones?NoYesIs the pet vomiting food or phlegm/bile?Does the pet gobble its food?NoYesHow long after eating does the pet vomit?Is there any history of recently eating garbage/table scraps/toys/strings?Have you tried a bland diet?NoYesMessageSubmit
