Dentistry Patient History Form

Owner Name *

First

Last

E-mail: *

Patient Name *

Problem/Complaint: *

List ALL clinics that have seen your pet for oral surgery or cleanings

Is your pet up-to-date on vaccines?

• Yes
• No

Past treatments for dental disease including cleanings:

Medications: Please include Dose (mg), How often given, Last given:

What are you feeding your pet? (include treats) Please specify brand, amount, how often:

Where did you get your pet?

Any travel outside of PNW?

What toys do you give your pet?

Any known allergies?

Are you brushing your pet's teeth?

What dental care products do you give your pet?

In recent history have you noticed any changes in… (check what applies)

• Drinking
• Appetite
• Weight
• Energy
• Urination
• Defecation
• Coughing
• Sneezing
• Vomiting

Drinking:

• Increased
• Decreased
• Normal

Appetite:

• Increased
• Decreased
• Normal

Weight:

• Increased
• Decreased
• Normal

Energy:

• Increased
• Decreased
• Normal

Urination:

• Increased
• Decreased
• Normal

Defecation:

• Increased
• Decreased
• Normal

Coughing:

• Increased
• Decreased
• Normal

Sneezing:

• Increased
• Decreased
• Normal

If your pet is vomiting, how often is it happening?

Describe any of the abnormal above:

Phone

Submit