Patient History Form - Sandia Animal Clinic

Please fill out this Patient History form and the Client Information form, and a member of our staff will call you to schedule your appointment.

Alternatively, you can print and fill out these forms and bring them with you to your appointment.

If this is an urgent matter or an emergency, please call our office during regular business hours or contact an ER.

Patient History

Date(Required)

Name(Required)

First Last

Pet's Name(Required)

Reason for Visit(Required)

Date of last vaccination(Required)

Date of last dental cleaning(Required)

Has your pet had previous bloodwork done? If yes, when and where?(Required)

Appetite (select one)(Required)

Any changes to your pet's diet?(Required)

Yes

If yes, please explain

Brand(s) of food given:(Required)

Feeding(Required)

Scheduled meals

Open bowl/free fed

Table scraps

Water consumption(Required)

Increased

Decreased

No change

Estimated daily water intake amount(Required)

Do you board your pet?(Required)

Yes

Is your pet experiencing lameness (limping)?(Required)

Yes

Constant

Intermittent

If yes, for how long?

Any notable behavior changes?(Required)

Yes

If yes, please explain

Is your pet experiencing vomiting?(Required)

Yes

If yes, how often?

Contents of vomit?

How soon does your pet vomit after eating?

Is your pet experiencing diarrhea?(Required)

Yes

Occasionally

Frequently

If yes, how many bowel movements per day?

Is your pet experiencing constipation?(Required)

Yes

When was your pet's last bowl movement?

Is your pet coughing?(Required)

Yes

Occasionally

Frequently

Is your pet sneezing?(Required)

Yes

Occasionally

Frequently

Does your pet have nasal discharge?(Required)

Yes

Pus

Watery

Bloody

If yes, for how long?

Is your pet itching?(Required)

Yes

Seasonal

Year round

If yes, where on the body?

Have you noticed any fleas or ticks recently?(Required)

Yes

Please list any medications and supplements regularly given(Required)

Previous veterinarian/clinic(Required)

Do you have any other questions or concerns?(Required)

Thank you for trusting us with your pet's care!

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