History for Wellness Exam

Date

Owner's Name

First Last

Pet's Name

Email

Have you noticed any coughing, sneezing or difficulty breathing?*

If yes, please explain

Has your pet been vomiting/ diarrhea?*

If yes, please explain

Does your pet have any ear problems (head shaking, scratching, sensitivity, odor, discharge)?*

If yes, please explain

Have you noticed any excessive itching or scratching?*

If yes, please explain

What diet do you feed your pet? (Brand, amount, wet/dry)

What treats or table food do you give your pet?

Is your pet eating and drinking normal?(or any increase in drinking)*

If abnormal, please explain

Does your pet have any increase in urination?*

If abnormal, please explain

Does your cat urinate or defecate outside of the litter box?*

If yes, please explain

What activities do you do with your pet for exercise?

What dental care do you provide at home?

Do you take your dog to a groomer, dog park, boarding facility, or stores where it could have contact with other dogs?

Do you travel with your pet? If so, where and how often?

Which flea/tick and heartworm preventative do you use? When did you give the last dose? Do you need any refills?

What medication is your pet on? (Please list all medication, what mg strength it is and how often they are given) Do you need any refills?

Does your pet have a microchip and if not would you like one at this visit?

Does your pet have any health or behavior concerns you want to discuss with the doctor?

What phone number should we use prior to or after your appointment?