Patient History Questionnaire

Owner Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Patient Information
Name
Age
Sex
Spayed/Neutered
- Yes
- No
Breed
Color
Previous Diagnosed Conditions
Define The Problem
1. What is the presenting complaint?
2. When was the last time your pet was normal?
3. What is the location of the problem?
4. Does anything make the problem seem better or less severe?
5. Does anything seem to make the problem worse or more severe?
6. Are there any other problems associated with the presenting complaint? (i.e. presenting complaint is that pet has diarrhea, but pet is now also vomiting.)
7. Has the problem improved at all over time, or has it seemed to progressively get worse?
Pain
8. Does your pet seem to be in any pain?
9. If yes, on a scale of 1-10 (1 being minimal, 10 being severe) what do you feel is your pets level of pain?
Medical History
10. Does your pet have any other current medical or surgical conditions? If so, list:
11. Does your pet have any known allergies? If so, list:
12. List any current medications your pet is on:
13. Have any previous tests been run on your pet? (i.e. X-rays, blood work, etc.)
14. Has your pet been vaccinated? If so how long ago and where?
Diet/Appetite/Water Intake
15. What is your pet’s current diet? (be as specific as possible. Include treats or any human food given.)
16. What is your pet’s appetite like?
17. What is your pet’s water intake like?
BMS/Urination/Vomiting
18. Describe your pet’s bowel movements: (consistency, color, frequency, amount, etc.)
19. Describe your pet’s urination: (color, amount, frequency, if any odor, any changes in routine, etc.)
20. If your pet is vomiting, please describe what the vomit looks like:
Additional Information
Has your pet recently been away from its normal environment?
(i.e. to a pet store, a dog park, wandered around the neighborhood, traveled out of the area, etc.)
21. Is your pet kept indoors, outdoors, or both? If outdoors describe the area where pet is kept. (i.e. shade, food, water, protection from weather, etc.)
22. Does your pet have any access to trash, chemicals, or any other hazardous materials? If so, list:
23. Does your pet chew on toys or other objects? If yes, have any gone missing lately, or have been chewed up?
24. Has your pet been under any kind of stressful event recently? If so, list: (i.e. boarding, traveling, company at your home, construction on your home, etc.)
25. List any other information about your pet that may be useful:

Contact

1113 B East Commerce Street
Lewisburg, TN , 37091

Hours

Monday: 7:45am – 5:30pm
Tuesday: 7:45am – 5:30pm
Wednesday: 7:45am – 5:30pm
Thursday: 7:45am – 5:30pm
Friday: 7:45am – 5:30pm
Saturday: 7:45am – 4:00pm
Sunday: Closed

Owner Information

Patient Information

Define The Problem

Pain

Medical History

Diet/Appetite/Water Intake

BMS/Urination/Vomiting

Additional Information

Contact

Hours