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Wellness History Form
Wellness History Form
Wellness History Form
Client Name
*
First
Last
Patient Name
What diet are you feeding (including treats or table foods?)
How much are you feeding?
How many times daily do you feed per pet (s)?
How often does your pet:
Visit the groomer?
Use a boarding kennel?
Go to day care?
What percentage of the time does your pet spend outdoors?
Have you noticed any:
itching/scratching
licking of the feet
skin growths
Have you noticed any:
scratching at the ears
smell from the ears
Is there any odor to the breath?
Y
N
Have you noticed any:
sneezing
coughing
discharge from the eyes or nose?
Have you noticed any limping?
Y
N
Does he/she have any trouble:
getting up
climbing stairs
jumping/running
Has there been any recent:
vomiting
diarrhea
scooting
If yes, how long ago and how often
Has there been any change in frequency or amount of urination?
Y
N
Has there been an increase in water consumption?
Y
N
Has there been a change in appetite?
Y
N
If yes,
Increased
Decreased
Has there been a change in sleep patterns?
Y
N
Has your pet had any accidents in the house?
Y
N
When was the last time you gave your pet any medications, heartworm/flea preventatives or any supplements (please list the name of each and when given):
Does your pet have any contact with wooded area?
Y
N
Are there any deer or wild animals that visit your yard?
Y
N
Do you take your pet camping or to lakes?
Y
N
Have you seen any stray dogs or cats in the neighborhood?
Y
N
Is there any long grass or tall weeds next to your yard in a common area or neighbor’s yard?
Y
N
How is mobility?
Limping
Skipping
Difficulty jumping
Difficulty with stairs
Do you need a refill on flea and tick or heartworm prevention?
Which brand of preventions are used?
Are they taking any other medications/supplements if so what?
Is there anything else that the doctor should know about?
*It is always best if you can collect and bring a fecal sample with you to your pet’s appointment.
CAPTCHA
Client Name
*
First
Last
Patient Name
What diet are you feeding (including treats or table foods?)
How much are you feeding?
How many times daily do you feed per pet (s)?
How often does your pet:
Visit the groomer?
Use a boarding kennel?
Go to day care?
What percentage of the time does your pet spend outdoors?
Have you noticed any:
itching/scratching
licking of the feet
skin growths
Have you noticed any:
scratching at the ears
smell from the ears
Is there any odor to the breath?
Y
N
Have you noticed any:
sneezing
coughing
discharge from the eyes or nose?
Have you noticed any limping?
Y
N
Does he/she have any trouble:
getting up
climbing stairs
jumping/running
Has there been any recent:
vomiting
diarrhea
scooting
If yes, how long ago and how often
Has there been any change in frequency or amount of urination?
Y
N
Has there been an increase in water consumption?
Y
N
Has there been a change in appetite?
Y
N
If yes,
Increased
Decreased
Has there been a change in sleep patterns?
Y
N
Has your pet had any accidents in the house?
Y
N
When was the last time you gave your pet any medications, heartworm/flea preventatives or any supplements (please list the name of each and when given):
Does your pet have any contact with wooded area?
Y
N
Are there any deer or wild animals that visit your yard?
Y
N
Do you take your pet camping or to lakes?
Y
N
Have you seen any stray dogs or cats in the neighborhood?
Y
N
Is there any long grass or tall weeds next to your yard in a common area or neighbor’s yard?
Y
N
How is mobility?
Limping
Skipping
Difficulty jumping
Difficulty with stairs
Do you need a refill on flea and tick or heartworm prevention?
Which brand of preventions are used?
Are they taking any other medications/supplements if so what?
Is there anything else that the doctor should know about?
*It is always best if you can collect and bring a fecal sample with you to your pet's appointment.
CAPTCHA
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1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.
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