Illness / Pet Injury History Form Owner Contact InformationName First Last Cell Phone to reach during visit*Pet Information - Required HistoryPet's NameIs your pet taking any medications?YesNoIf 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?*YesNoDoes your pet come into contact with other animals not in your home? (Check all that apply.) None Boarding Grooming Dog Parks 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.?YesNoAppointment InformationWhat's the reason for your visit? (Check all that apply) Appetite Change Changes in drinking Weight Loss Weight Gain Itching/Scratching Shaking Head Bad Breath Vomiting Diarrhea Changes in urination Excessive Sleeping Scooting Difficulty getting up Skin Masses (explain below) Behavioral concerns (explain below) Changes in activity Limping Fur loss Coughing/Sneezing Eye discharge/Squinting Seizures Other - Explain When did you start noticing the problem?Has your pet had this problem in the past?*YesNoDid you give your pet any medications or treatments for this issue?*YesNoIf so, please indicate what / when*When is the last time your pet ate?*What is your pet's typical diet? Include Brand, Type (Wet/Dry), Amount Fed, Number of Feedings, Table Food, Treats, etc.*Has your pet ever had any adverse reaction to any medications, vaccination, or other procedure?*YesNoOther procedures requested: Anal Gland Expression Nail Trimming Ear Cleaning Do you need an estimate prior to visit?YesNoAny additional information you feel would be helpful for the doctor?