Call: 978-632-7110
Text: 978-632-7110
73 Eaton Street Gardner, MA 01440
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Patient History Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone
*
Are you currently a client of GACC?
No
Yes
Pet's Name
Pet's Species
Canine
Feline
Pet's Breed
Pet's Age
Under 1 Year Old
Between 1 and 7 Years Old
7 Years or Older
Where does your pet spend the majority of their time?
Inside
Outside
Both
Does your cat hunt?
No
Yes
How 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?
No
Yes
If yes, please list all preventive medications.
Is your pet currently taking any other medications or supplements?
No
Yes
If yes, please list all supplements and medications.
Reason for upcoming visit:
Does your pet have any preexisting medical conditions we should know about?
No
Yes
Please list all medical conditions here.
Has your pet traveled recently?
No
Yes
Are there other pets in the household?
No
Yes
Please list all additional cats, dogs, and other pets.
Is your pet in need of a recheck from a previous exam?
No
Yes
Is 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?
No
Yes
Is 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?
No
Yes
Does 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?
No
Yes
Are 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?
No
Yes
Please 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?
No
Yes
If yes, please explain.
Are there any behavioral concerns?
No
Yes
If yes, please explain.
Has the pet been able to bear weight normally on all four legs?
No
Yes
Which leg(s) are affected? Is it a shifting leg lameness?
Has it been an acute and rapid onset?
Have you noticed any swelling?
No
Yes
Have you seen any blood?
No
Yes
Have you noticed any issues with your pet's mouth, teeth, or gums?
No
Yes
Is there severe odor?
No
Yes
Does the pet favor one side of the mouth when they eat?
No
Yes
Is there a history of trauma?
No
Yes
Is there any excessive drooling?
No
Yes
Does the pet paw at its mouth?
No
Yes
Has the pet changed its food preference (i.e. hard/semi-soft/canned)?
No
Yes
Do you have an at-home dental plan you follow?
No
Yes
Have you noticed any issues with your pet's nose or throat?
No
Yes
Has the pet's appetite changed?
No
Yes
Are there any difficulties swallowing?
No
Yes
Is there any sneezing, nasal discharge or bleeding?
No
Yes
If discharge is present, is it from one or both nostrils?
Left
Right
Both
Is there any time of day or situation where the symptoms are worse?
No
Yes
Changes in sleeping behavior?
No
Yes
Please describe your pet's change in sleeping behavior.
Does your pet have a history of seizures?
No
Yes
How 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)?
No
Yes
Does your pet swim, urinate and/or defecate during the seizure?
No
Yes
Does your pet have a history of skin issues?
No
Yes
Is your pet scratching (pruritic?)
No
Yes
Is your pet chewing/licking the lesion or feet/tail?
No
Yes
Have you seen any fleas or other parasites on the pet?
No
Yes
Does the lesion appear to be spreading or increasing in number?
No
Yes
Have you tried any medication? Please list them here.
Is your pet experiencing any issues with urination?
No
Yes
Is your pet unable to urinate or straining with no success?
No
Yes
Is the urine a normal color, amount, and frequency?
No
Yes
Are 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?
No
Yes
Is there a particular time of day/night it occurs?
Did you recently open a new bag of food?
No
Yes
Did you recently buy new treats/rawhides/bones?
No
Yes
Is the pet vomiting food or phlegm/bile?
Does the pet gobble its food?
No
Yes
How 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?
No
Yes
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