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Patient History Form

Name *

First

Last

Email *

Phone *

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Are you currently a client of GACC?

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?

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?

If yes, please list all preventive medications.

Is your pet currently taking any other medications or supplements?

If yes, please list all supplements and medications.

Reason for upcoming visit:

Does your pet have any preexisting medical conditions we should know about?

Please list all medical conditions here.

Has your pet traveled recently?

Are there other pets in the household?

Please list all additional cats, dogs, and other pets.

Is your pet in need of a recheck from a previous exam?

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?

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?

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?

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?

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?

If yes, please explain.

Are there any behavioral concerns?

If yes, please explain.

Has the pet been able to bear weight normally on all four legs?

Which leg(s) are affected? Is it a shifting leg lameness?

Has it been an acute and rapid onset?

Have you noticed any swelling?

Have you seen any blood?

Have you noticed any issues with your pet's mouth, teeth, or gums?

Is there severe odor?

Does the pet favor one side of the mouth when they eat?

Is there a history of trauma?

Is there any excessive drooling?

Does the pet paw at its mouth?

Has the pet changed its food preference (i.e. hard/semi-soft/canned)?

Do you have an at-home dental plan you follow?

Have you noticed any issues with your pet's nose or throat?

Has the pet's appetite changed?

Are there any difficulties swallowing?

Is there any sneezing, nasal discharge or bleeding?

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?

Changes in sleeping behavior?

Please describe your pet's change in sleeping behavior.

Does your pet have a history of seizures?

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)?

Does your pet swim, urinate and/or defecate during the seizure?

Does your pet have a history of skin issues?

Is your pet scratching (pruritic?)

Is your pet chewing/licking the lesion or feet/tail?

Have you seen any fleas or other parasites on the pet?

Does the lesion appear to be spreading or increasing in number?

Have you tried any medication? Please list them here.

Is your pet experiencing any issues with urination?

Is your pet unable to urinate or straining with no success?

Is the urine a normal color, amount, and frequency?

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?

Is there a particular time of day/night it occurs?

Did you recently open a new bag of food?

Did you recently buy new treats/rawhides/bones?

Is the pet vomiting food or phlegm/bile?

Does the pet gobble its food?

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?

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