Patient History Form

First Name

Last Name

Date

Pet’s Name

Age

Any weight changes?

Severity?

When did the problem begin?

Changes to appetite?

Severity?

When did the problem begin?

Vomiting?

When did the problem begin?

Diarrhea/Soft Stool?

When did the problem begin?

Constipation/Difficult defecation?

When did the problem begin?

Increased thirst / urination?

When did the problem begin?

Any skin problems?

Severity?

When did the problem begin?

Scratching ears / Shaking head?

When did the problem begin?

Bad breath/sore gums / difficulty chewing?

When did the problem begin?

House soiling/spraying?

Explain

When did the problem begin?

Decreased recognition of people, animals, or previously learned commands?

Describe

When did the problem begin?

Decreased affection/interaction with owner?

When did the problem begin?

Decrease awareness (gets lost/confused)

When did the problem begin?

Chewing , licking, eating non-food items?

Describe

When did the problem begin?

Increased irritability /aggression?

When did the problem begin?

Increased fear, anxiety?

When did the problem begin?

Decreased tolerance for handling?

When did the problem begin?

Decreased or selective hearing?

When did the problem begin?

Repetitive Behaviors (ie. Pacing, overgrooming, circling)

When did the problem begin?

Muscle tremors/shaking/ seizures?

Describe

When did the problem begin?

Weakness/incoordination?

When did the problem begin?

Difficulty climbing stairs/stiffness?

When did the problem begin?

Decreased activity – sleeps more

When did the problem begin?

Excessive vocalization?

Severity?

When did the problem begin?

Waking owner(s) at night?

When did the problem begin?

Patient History Form

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