New Client Health History Questionnaire Fill out our online form or download a printable version CLIENT INFORMATIONName for account:* Name of Pet:* Date of Appointment:* MM slash DD slash YYYY Time of Appointment:* : Hours Minutes AM PM AM/PM Date of Birth or Age of Pet:* Sex of Pet:* Male Male – neutered Female Female – spayed Primary issue(s)/concern(s) and approximate duration of each:*DIET TYPES AND DURATIONSCurrent diet and for how long (include treats):* Past diet types and how long:* What was the response to each:* Know or suspected food allergy or intolerances:* VACCINATION AND DRUG HISTORYCurrent supplements or drugs (please list name, strength and how often):*Current supplements or drugs (please list name, strength and how often):*Past drug history (steroids, antibiotic, use (which ones and responses):*Vaccination history (gets all on time, only do minimal vaccinations, don’t do any vaccinations):*Current on heartworm test and preventatives?* Yes No Any reactions to vaccinations? Yes No Which ones and what happened?* Previous illness history (other than primary concerns):*PERSONALITY/CHINESE CONSTITUTION Wood (the boss) Fire (super excitable but usually friendly) Earth (easy going, friendly, usually food motivated) Metal (I follow all of the rules, don’t get very upset) Water (scared, hides) Become grouchy or bite if doing something he/she doesn’t like? Tends to like areas that: Are very quiet Are very active/exciting Anywhere TEMPERATURE PREFERENCE Cool seeking(hard floors, A/C vents) Heat seeking (warmer bedding, heater vents Seeks out softer spots instead of temperature differences Hate to go out when it is: Hot (Get overheated easily?) Cold If applicable, are there spots on your pet that feel hot to you? If applicable, are there spots on your pet that feel cold to you? Panting when you think he/she should not (like at rest?)* Yes No WATER CONSUMPTION Less than expected Average More than others: Always at the bowl Tanks up all at once Drinks alot throughout the day APPETITE Normal Decreased Shows interest but does not eat Ravenous Pica (eats weird things): None Stool Grass Garbage VOMITINGDoes your pet vomit?* Yes No How often?* Burping a lot after eating Drooling but won’t eat Contains: Bile Fur Food (fresh) Food (digested) Blood (black) Blood (red) Mucous STOOL QUALITY Normal Loose Mucoid Bloody (red) Bloody (black) Watery Very Dry Odor to stool: Not very smelly Very smelly Flatulance: None Some Too much SKINTends to be: Normal Dry Greasy Large flake Fine flake Dry lesions Moist lesions Locations of lesions (if any): Itching tends to be where (if appropriate): Ear issues: COUGHING/SNEEZINGCoughing: None Dry Honking Productive Worse In: AM PM All the time Sneezing? Yes No Any discharges from nostrils and which nostril: URINATIONS Normal Little amounts Large amounts/accidents inside Very concentrated (maybe kills grass) Very dilute Unsure of concentration CONDITION WORSE WITH… Nothing Activity/Movement After laying around Change in weather/heat/cold/dampness At waking or during night time Or any time listed below: LU (3-5am) LI (5-7am) ST (7-9am) SP (9-11am) HT (11am-1pm) SI (1-3pm) BL (3-5pm) KID (5-7pm) PC (7-9pm) TH (9-11pm) GB (11am-1pm) Liv (1-3pm) Sleeping okay? Yes No Lots of dreams? Yes No AGILITY SPECIFIC QUESTIONSWhat venue is run (AKC, USDAA, NADAK, UKC, CPE)? Reason for visit or cause on non-Q? Any refusals, flyoffs, floor slips if not listed above? CAPTCHA Δ
