Canine History Intake Form
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Client Name *
Email *
Phone Number *
Patient Name *
Patient Age *
Appointment Date *
Where did you get your pet and how long ago? *
Are there other pets in your home?  If yes, please list species and if they interact with each other. *
Are there young children in the household? *
What are you currently feeding your pet?  Please list brand, how much and how often are you feeding per day. *
How is your pet’s appetite? *
Any vomiting or diarrhea?  If yes, please list when the symptoms started, how frequent and descriptions. *
Any coughing or sneezing?  If yes, please list when the symptoms started, how frequent and descriptions. *
Has there been any change in your pet’s water intake or urination? *
How is your pet’s energy level? *
Is your pet having any problems with lameness or stiffness?  If yes, please list when the symptoms started, how frequent and descriptions. *
Is your pet on any flea and tick preventative? If yes, please list the name of the product and when the last dose was given. *
Is your pet on any heartworm preventatives?  If yes, please list the name of the product and when the last dose was given. *
What types of dental care/maintenance do you do at home? *
What is your pet’s tick exposure (travel history, exposure to wooded areas/tall grass). *
Do you give your pet any medications or supplements?  If yes, please list medication name, strength, and how often it is given. *
Has your pet received any previous vaccines? *
Does your pet have any history of vaccine reactions?  If yes, please explain. *
If a puppy, has your pet been dewormed? *
Is your pet spayed/neutered? If not, do you have plans to spay/neuter, breed, or are you unsure at this time? *
Are you having any issues with house-training or obedience?  If yes, please explain. *
Is there anything in your pet’s history we need to be aware of?  Please list chronic issues, surgeries, irregular blood work, diagnoses and medical conditions. *
Do you have any concerns about your pet today? If yes, please explain. *
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