Pet History Form Name* First Last Pet's NameReason for appointment:*Wellness CareInjury or IllnessDo you have any specific concerns about your pet?YesNoPlease describe your concerns.How is your pet eating? What is their current diet? How much do they eat daily?Have they been urinating normally?YesNoDoes your pet have normal drinking?YesNoPlease explain*Has there been any vomiting?YesNoIf yes, please describe.Has there been any diarrhea?*YesNoIf yes, please describe.*Has there been any coughing?YesNoIf yes, please describe.*Has there been any itchiness or other skin concerns?YesNoIf yes, please describe.*Have you noticed any new skin lumps or have concerns about previously examined skin lumps?*YesNoIf yes, please describe which lumps and where they are on your pet.Have you noticed any signs of pain or poor mobility?YesNoPlease describe.*Have you noticed any changes in energy or exercise tolerance?YesNoPlease describe changes.*Have you noticed any changes in behavior?YesNoPlease describe any changes in behavior.*Does your pet take any supplements?YesNoPlease list the supplements they are taking.* Does your pet take any medications?YesNoIf yes, please list the medications they are taking, and doses if possible.*NameDosage Do you need any refills on any of your pet’s medications or supplements today?YesNoRefills Have you traveled anywhere recently with your pet?YesNoWhere have you traveled?*Please list anything else you would like to address while you and your pet are here today.