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Patient History 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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