Patient Health History Form – North Tustin Veterinary Clinic

Pet Owner’s Name*

First Last

Phone Number*

Email*

Patient Name*

Date*

MM

DD

YYYY

Is your pet eating and drinking normally?*

Yes
No

If No, Please describe symptoms and duration

What diet is your pet currently on?*

Has your pet been experiencing vomiting or diarrhea?*

Yes
No

If Yes, Please describe symptoms and duration

Is your pet coughing or sneezing?*

Yes
No

If Yes, Please describe symptoms and duration

Is your pet currently taking a flea/tick preventative?*

Yes
No

If Yes, Please list the product name and frequency given:

Is your pet currently taking a heartworm preventative?*

Yes
No

If Yes, Please list the product name and frequency given:

Is your pet currently taking prescription medication(s)?*

Yes
No

If Yes, Please list the medication name(s), frequency given, and prescriber’s name:

If Yes, Please list the condition for which your pet’s medication was prescribed:

Do you need medication refills?*

Yes
No

If Yes, Please list the medication name(s), frequency given, and prescriber’s name:

Does your pet have anxiety?*

Yes
No

If Yes, Please describe symptoms and activities surrounding anxiety episodes:

Have you noticed your pet behaving abnormally recently?*

Yes
No

If Yes, Please describe symptoms and duration:

Does your pet spend time scratching/licking/chewing their skin/fur?*

Yes
No

If Yes, Please describe symptoms and duration:

Does your pet experience stiffness/soreness?*

Yes
No

If Yes, Please describe symptoms and duration:

Have you noticed any new lumps or growths on your pet?*

Yes
No

If Yes, Please describe describe the location and when the change was first noticed:

What is your pet’s typical environment (i.e. stays at home, visits local dog parks/attractions, travels frequently)?

Are you planning to board your pet in the near future?*

Yes
No

If Yes, Please list upcoming boarding dates and facility:

Has your pet stayed at a boarding facility since your last visit?*

Yes
No

If Yes, Please list most recent boarding dates and facility:

Please list any additional health history you’d like to share: