Oncology Patient History Form

Owner Name *

First

Last

E-mail: *

Patient Name *

Problem/Complaint: *

Is your pet up-to-date on vaccines?

• Yes
• No

Recent treatments for current problem:

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

What are you feeding your pet? Please include any supplements, vitamins, or herbs

Any known allergies? If so please explain

Is it ok to give your pet treats during your appointment? (We’ve been known to give cookies to our patients:))

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

• Drinking
• Appetite
• Weight
• Energy
• Urination
• Defecation
• Coughing
• Pain/Lameness:
• 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

Pain/Lameness:

• Increased
• Decreased
• Normal

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

Other comments

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