Annual Pet History Form Owner Contact InformationName* First Last Cell Phone to reach during visit*Pet Information - Required HistoryPet's Name* Is your pet taking any medications?* Yes No If so, please list them here* What percentage of time does your pet spend outside?* 0% 50% 100% Have you seen any fleas or ticks on your pet?* Yes No Does your pet come into contact with other animals not in your home? (Check all that apply.) None Boarding Grooming Dog Parks Stray Cats on porch/in yard Other (Training Class, Pet Stores, Neighborhood, etc.) Does your pet have exposure to water sources/wildlife. i.e. Rabbits, deer, turkey, creeks/streams, puddles, etc.? Yes No Appointment InformationWhat's the reason for your visit? (Check all that apply)* Annual Physical Fecal/intestinal parasite screen Puppy/Kitten Visit Vaccinations Heartworm/Tickborne Disease Testing What tick/flea/heartworm prevention is your pet on? (Check all that apply.)* Sentinel Spectrum Advantage Multi Seresto Bravecto Revolution Plus Nexgard None Other Brand Name* Please refill my pet's heartworm or flea prevention. This is recommended once monthly, given year-round.* Yes No For...* 3 months 6 months 12 months If yes, please indicate the number of doses requested: 3/6/12 months My pet's diet consists of: Brand, Type (Wet/Dry), Amount Fed, Number of Feedings, Table Food, Treats, etc.* Other procedures requested:* Anal Gland Expression Nail Trimming Ear Cleaning None Are there any concerns for the following: (Check all that apply.) Appetite Change Changes in drinking Weight Loss Weight Gain Itching/Scratching Shaking Head Bad Breath Vomiting Changes in stool Changes in urination Excessive Sleeping Scooting Difficulty getting up Skin Masses (explain below) Behavioral concerns (explain below) Changes in activity Limping Fur loss Coughing Other - Explain If there are concerns, how long has your pet been experiencing this problem and what symptoms have they been experiencing?*Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?* Yes No Do you need any refills of medication?* Yes No What are the names of the medications you need refilled at your visit?* Please complete my pet's annual preventative bloodwork (Geriatric bloodwork, Heartworm/Tickborne Disease Test, etc.)* Yes No Do you need an estimate prior to visit?* Yes No Any additional information you feel would be helpful for the doctor?*Signature* Type Name
