Pet History/Check-in Form

Pet History/Check-In Form

Name *

Name

First

Last

Pet Name *

Please provide the date of your appointment *

Please provide the time of your appointment *

:

List your pet’s current medications, supplements, and flea and heartworm control. Please include the strength and the frequency of administration. *

What is your pet eating? Please list the brand, quantity, and frequency. *

What insurance does your pet have? *

Does your pet travel outside of Jefferson County? *

Yes

No

Please list the cities and states:

Describe your feline pet's environment

Indoor only

Indoor/Catio/Screened Porch

Indoor/Outdoor

Outdoor only

General Health: please mark any areas where you have noticed changes *

Changes in appearance (e.g., weight gain or loss, skin or hair coat, or swellings)

Changes in mobility (e.g., difficulty getting up and down, reluctance to go on walks, changes in gait, or accessing favorite perches and sleeping locations)

Changes in behavior or attitude (e.g., increase in aggression, withdrawal from normal routine, or inappropriate urination)

Changes in the amount of eating, drinking, or urination

None of the above

If you selected any of the above, please give further details with specific examples seen, when the changes were first noticed, whether it seems to be worsening, and any other details you can share. *

If your pet is being seen for a specific problem, please continue with the questions below.

What concern is your pet in for today? Is this a new issue or ongoing? When did it start and is it stable or worsening? Please share any other details or observations you may have

Have you or another veterinarian provided measures to assist the problem?

If you are human, leave this field blank.