New Patient Medical History Questionnaire Pet's Name*(Required)Date MM slash DD slash YYYY What is your primary concern about your pet today:Is your pet current on vaccinations? Yes No Do you have pet insurance? Yes No What food does your pet eat?Are there any lumps or bumps on your pet? Yes No If Yes… Where?Has there been a recent change in your pet’s behavior Yes No If Yes… DescribeHas your pet been treated for any previous medical conditions or surgery? Yes No If Yes…When and for whatWhat was the reason for being hospitalizedHas your pet’s activity level changed recently? Yes No If Yes… Has it increased or decreased?Has your pet’s appetite recently changed? Yes No If Yes… Has it increased, decreased, not eating at all?Has your pet’s weight changed recently? Yes No If Yes… Has it increased or decreased?Has your pet’s water intake changed recently? Yes No If Yes… Has it increased or decreased?Has your pet been vomiting recently? Yes No If Yes…Frequency per day/per weekHas your pet’s defecations changed recently? Yes No If Yes… Diarrhea, straining to defecate, blood in feces, mucus in feces?Have your pet’s urination habits changed recently? Yes No If Yes… Has it increased or decreased, straining to urinate, blood in urine?How long have you owned your pet?Where was your pet obtained?If Yes... Please list current medicationsIs your pet on any current medications? Yes No For Emergency Consults/Same Day Surgery Patients Only:Was food withheld for today's visit? Yes No What time was you pet last fed?Additional CommentsPhone*(Required)Email*(Required)Thank you for taking the time to fill out the questionnaire
