Comprehensive Patient History

(Fields marked with an * are required.)

Annual Wellness Exam
Comprehensive Patient History

Client Information

Title:
* First Name:  Middle Initial: * Last Name:
* Appointment Date: * Appointment Time:
* Pet’s Name:

Reason for Visit

* Mark all that apply:

Annual wellness examination
Vaccinations
Annual blood panel/stool testing
Other specific concerns (please describe):
Are your pet’s vaccinations up to date?
Yes No Don’t know
Is your pet spayed/neutered?
Yes No Don’t know
Does your pet travel outside of San Francisco?
Yes No
If yes, where does he/she go?

Preventatives

Is your pet on monthly preventative(s) for:
Fleas?
Yes No Brand:
Heartworm?
Yes No Brand:
Intestinal parasites?
Yes No Brand:
Have you seen any worms recently?
Yes No

Diet

What diet do you feed? (Brand and Type):
How much/how frequently do you feed your pet?
Treats given:
Does your pet have any food intolerances?
Yes No

Tell us how your pet is feeling

Any injury or illness in the past 30 days?
Yes No
Does your pet have a history of seizures?
Yes No
Is your pet allergic to any drugs/medications/VACCINES?
Yes No
Which one(s)?
Appetite:
Normal Decreased Increased
Weight:
Normal Decreased Increased
Water Consumption:
Normal Decreased Increased
Bowel Movements:
Normal Decreased Increased
Urination:
Normal Decreased Increased
Inappropriate Urination (loss of housetraining or not using litter box):
Yes No
Vomiting Yes No
Diarrhea Yes No
Coughing Yes No
Sneezing Yes No
Gagging Yes No
Listlessness Yes No
Weakness Yes No
Shaking Head Yes No
Excessive Scratching Yes No
Hair Loss Yes No
Scooting Yes No
Unusual Lumps Yes No
Bad Breath Yes No
Unusual Discharge Yes No
Limping Yes No
General Stiffness Yes No
Stiffness After Exercise Yes No
Stiffness After Sleeping Yes No
Tires Easily Yes No
Behavior Changes Yes No