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Please print this form. You may drop it off, fax it 603-425-7647, or mail it to the office at 33 Crystal Ave., Derry, NH 03038, or bring it in to your appointment, or email it to info@handelwithcarevet.com.
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Patient History Questionnaire
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Pet's First Name: ______________ Last Name: ________________________ Birthdate:_________________
Owner's Name: ____________________________Address: ________________________________________
Phones: Home: ________________ Work: ______________________ Cell: ________________________
Emergency Contact: _________________________________Phone: _____________________________
Food
Wet Food Brand: ____________________Amount: ______ Dry Food Brand: _____________________Amount ____
Treats: _____________________________________________________How Often? ___________________
Table Scraps? Y/N What Kind? _____________________________________________________________
Do you feed your pet any dietary supplements? If so, what?
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Health - Please check all that apply.
o Increase in appetite
o Decrease in appetite
o Not eating
o Increased thirst
o Not drinking
o Frequent urination
o Frequent diarrhea or loose stools
o Increase in quantity of urine
o Strains to urinate or defecate
o "Scoots" rear along floor
o Wakes me to go out at night
o Misses litter box
o Urinates or defecates in places other than the
than the box
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o Blood in urine or stool
o Leaves a "puddle" of urine when she gets up
o Vomits daily or weekly
o Coughs frequently
o Sneezes frequently
o Scratches or is itchy frequently
o Licks or scratches at ears, paws or belly
o Noticeable hair loss
o Bumps or Lumps?
o Pain
Spends time in litter box with no production |
o Labored Breathing
o Limping (associated with exercise) or upon rising
o Lethargy
o Difficulty walking or climbing stairs
o Stares off into space
o Disturbance in sleep/wake cycles
o Paces
o Reduced social interaction with owner
o Loss of normal house training
o Does not recognize friends or family
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Behavior
Please check all that apply.
- High activity level
- Moderate activity level
- Sedentary
- Decreased activity level
- Goes outside frequently
- Indoors Only
- Outdoors Only
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o Walks in woods
o Walks in city
o Exposed to other pets
o Boards Frequently
o Travels Frequently
o Exposed to wildlife near home
o Goes near streams, stagnant water
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o Obedience/training classes
o Doggie Daycare
o Contact with neighborhood pets
o Dog Park
o Repetitive behaviors
o Any new experiences such as bathing, fireworks, moving, new pet, new baby, visitors?
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Have you noticed any behavioral changes? Y/N If yes, please elaborate.
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Have you visited another veterinarian since your last visit here? Y/N If yes, please elaborate.
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Is there anything you'd like to discuss with the doctor?
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Year Round Heartworm medication: __________________________
Year Round Flea/Tick Preventive: _______________________
Medications (Not necessary if we regularly see your pet, and your pet hasn't been elsewhere.)
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Previous Veterinarian: ___________________________________ Phone: ____________________________
(if applicable)
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We appreciate your time in completing this survey of your pet's health. Thank you for your help in making your pet's visit extremely thorough and productive!
Handel with Care Veterinary Hospital, LLC
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