Emergency & Critical Care Patient History Form

Pet's Name *

Owner's Name *

First

Last

E-mail: *

Date / Time

Date

Time

Problem/Complaint: *

When did this problem start? *

Has your pet been treated for any medical or surgical problems previous to this visit? If yes, describe:

How long have you owned your pet?

Are there other pets in the household?

Is your pet:

• Female
• Spayed Female
• Male
• Neutered Male

If not spayed, when was her last heat?

Is she pregnant?

• Yes
• No

When was your pet last vaccinated against viral disease?

Rabies?

Cats only: Has your cat been tested for FELV / FIV?

• Yes
• No

Results?

Is your pet currently receiving any medications to prevent heartworm / fleas / ticks? Please list type of medication used:

Is your pet indoor / outdoor / both?

• Indoor
• Outdoor
• Both

If outside, are they supervised?

• Yes
• No

Do they have neighborhood access?

• Yes
• No

Has your pet had access to raw fish?

• Yes
• No

Access to garbage?

• Yes
• No

What kind of food does your pet normally eat?

Access to table scraps or meat bones?

• Yes
• No

If yes, please specify:

Is your pet currently taking any medications?

• Yes
• No

If yes, please list (please include any pain medications, vitamins / supplements):

Has your pet ever had a reaction to or side effects from a medication?

• Yes
• No

If yes, please list:

Has your pet ever had a seizure?

• Yes
• No

The following questions are based on the last 24 - 48 hours

Has there been any change to your pet's energy level or behavior recently?

• Yes
• No

If yes, please describe:

Has there been an increase or decrease in your pet's appetite recently?

• Increase
• Decrease
• No Change

Has there been an increase or decrease in your pet's water intake recently?

• Increase
• Decrease
• No Change

Has your pet had any vomiting?

• Yes
• No

When did it start?

How often, how much?

Has your pet defecated recently?

• Yes
• No

When was the last normal stool?

Any diarrhea?

• Yes
• No

Any straining?

• Yes
• No

Any blood?

• Yes
• No

Does your pet have a history of urinary problems?

• Yes
• No

Is your pet urinating more frequently than normal?

• Yes
• No

Any straining to urinate?

• Yes
• No

Any blood in the urine or discoloration?

• Yes
• No

Is your pet coughing?

• Yes
• No

When did it start?

Describe:

Is your pet sneezing?

• Yes
• No

When did it start?

Is there any nasal discharge or bleeding?

Is your pet currently taking any medications?

• Yes
• No

If yes, please list (please include any pain medications, vitamins / supplements):

Has your pet ever had a reaction to, or side effects from a medication?

• Yes
• No

If yes, please list:

Other comments/observations/notes:

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