ACAH Pet History Questionnaire - ADAIR COUNTY ANIMAL HOSPITAL & LASER SURGERY CENTER

ADAIR COUNTY ANIMAL HOSPITAL & LASER SURGERY CENTER

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Patient History Questionnaire

For a faster exam visit, please fill out the following history questions about your pet BEFORE your appointment. Submit one questionnaire per pet.

Options:

1.) Instant: Fill out the patient history on this page and submit it electronically by clicking "SUBMIT" at the bottom. You will be sent back to our website's home page as a confirmation that this questionnaire was received.

2.) Print and Return: You may also fill out the patient history form by hand by printing the attached PDF file. Bring it with you to your pet's appointment.

Printable Patient History Questionnaire
File Size:	102 kb
File Type:	pdf

To continue to improve the service and communication we provide, we will be testing several different forms and form styles. Feel free to give us some feedback. We appreciate your patience as we grow in excellence!

* Indicates required field

Pet's Name *

Date of Scheduled Appointment: *

Client First & Last Name *

First

Last

Client Type *

NEW CLIENT -- Please bring a copy of your pet's vaccination history with you to their appointment and all current medications! EXISTING CLIENT

Primary Phone Number *

The previous primary phone number listed is a: *

Cell Phone Home Phone

MEDICATIONS:

Is your pet on any medications? *

Yes No

If yes, list any current maintenance medications, this includes oral, medicated shampoos, injections, topicals, etc. Please bring all current medications to your pet's appointment.

What heartworm preventative do you give your pet? *

None Simparica Trio ProHeart 6 Injections Revolution Plus Sentinel Spectrum Other

When was the heartworm prevention given last? If none given, type "N/A." *

Do you need a refill of your pet's heartworm preventative today? *

Yes No

What adult flea and tick preventative do you give your pet? *

None Simparica Trio Seresto Collar Nexgard Revolution Plus Other

When was the flea and tick prevention was last given. If none given, type "N/A." *

Do you need a refill of your pet's adult flea/tick preventative today? *

Yes No

Medication #1: Name & Strength: *

Medication #1 Frequency: *

Do you need a refill of this medication today? *

YES, please refill. No

Medication #2: Name & Strength: *

Medication #2 Frequency: *

Do you need a refill of this medication today? *

YES, please refill. No

Medication #3: Name & Strength *

Medication #3: Frequency *

Do you need a refill of this medication today? *

YES, please refill. No

DAILY CARE:

What's your reason for this visit? And do you have any specific questions or concerns about your pet today? *

Food: What BRAND(s) and TYPE(s) of food are you feeding? (List all Can / Dry / Specific Human Foods) *

How is your pet's eating? *

Normal Abnormal, I've noticed an increase. Abnormal, I've noticed a decrease.

How is your pet's drinking? *

Normal Abnormal, I've noticed an increase. Abnormal, I've noticed a decrease.

How is your pet's urination? *

Normal Abnormal, I've noticed an increase. Abnormal, I've noticed a decrease.

How are your pet's bowel movements? *

Normal Abnormal

Has your pet experienced any diarrhea recently? *

Yes No

Has your pet had any vomiting recently? *

Yes No

Has your pet been coughing recently? *

Yes No

Has your pet had any sneezing recently? *

Yes No

Have you noticed your pet scratching or itching anywhere? *

Yes No

Have you noticed your pet biting or licking themselves anywhere? *

Yes No

Does your pet have any allergies that you're aware of? (Seasonal, Food, Environmental, Medication, etc.) *

Yes No

Has your pet shown any signs of being in pain or have any lameness? *

Yes No Maybe

What's your pet's current activity level? *

Normal Abnormal

Do you perform any pet dental care at home? *

Yes No No, but I would like to start!

If yes, please select all dental care used: *

Teeth Brushing Water Additive or Rinse Chew None

Please name the dental products you use AND how often they are used. *

WRAPPING UP:

List any additional medications/strengths and frequency given here. *

Help us! How did you hear about us? (Pick ALL that apply.) *

DVM Referral Friend / Family Member ACAH & LSC Staff Member Internet Search Facebook Instagram YouTube Billboard Ad Drove by our location Other

Of the programs and services available at Adair County Animal Hospital and Laser Surgery Center, today I would like more information about: *

Wellness Plans Pet Insurance Vaccines & Parasite Prevention At-Home Dental Health & Routine In-Office Cleanings Boarding, Daycare, or Grooming Laser Surgeries or Lab Work Canine Massage Therapy Laser Therapy Client Referral Program or Client Loyalty Program Financial Assistance: ScratchPay or Care Credit None, thank you anyway!

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Adair County Animal Hospital & lASER sURGERY cENTER

(Main Office) 270-384-6113
2004 Campbellsville Road, Columbia, KY 42728

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About Us
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Contact Us
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Wellness Plans
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Training