Well Pet History Form

Please complete this form at least 24 hours prior to your scheduled appointment. Completing this document prior to your appointment will help us to check you in more quickly

Pet Name*
Owner Name*
First Last
Phone number associated with your account*
Today's Date*
MM
DD
YYYY
Please tell us about your pet's current diet and treats. Please include the brand, amount, and frequency of feedings*
Please tell us about any medications your pet receives. Please include the mg of the medication, amount given, and frequency of administration. Please include any supplements and heartworm/ flea/ tick prevention.*
Has your pet had any vomiting or diarrhea? If yes, please explain*
Has your pet had any coughing or sneezing? If yes, please explain*
Have you noticed any changes in your pet's drinking or urination habits? If yes, please explain*
Have you noticed any new lumps or bumps? If yes, please explain*
Have you noticed any changes to your pet's mobility? If yes, please explain*
Do you have any behavioral concerns? If yes, please explain*
Does your pet have a history of vaccine reactions? If yes, please explain*
Does your pet board at Huffard Animal Hospital now or in the future?*
- Yes
- No
Cat patients only- Is your cat...
- Indoor
- Outdoor
- Indoor and Outdoor
Cat patients only- Has your cat been using the litter box appropriately? If not, please describe the problem and your current litter box set up (location, number, litter, type of box, etc)
Do you have any other concerns you would like the veterinarian to address during your appointment? If yes, please describe below
Do you have any additional services (nail trim, ear cleaning, anal gland expression, etc) that you would like done while your pet is with us? Please describe below.
Do you need refills of any medications (including heartworm and flea/ tick preventatives) while you are here? Please include the name and mg of the medication, how you are currently giving it (ie 1/2 tab once daily), and how much you would like (ie 6 mo supply or 60 tabs) *

Well Pet History Form

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