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

ADAIR COUNTY ANIMAL HOSPITAL & LASER SURGERY CENTER

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Patient Exam- History Questionnaire

* Indicates required field

Date of Scheduled Appointment: *

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

NEW CLIENTS: Have you ever owned a cat or dog before? *

No, I am a new cat owner. Yes, I am a seasoned cat owner. No I am a new dog owner. Yes, I am a seasoned dog owner.

Client First & Last Name *

First

Last

Primary Phone Number *

The previous primary phone number listed is a: *

Cell Phone Home Phone

Patient Name *

Daily Care:

Describe your pet's current energy level: *

Eating: Any increase or decrease with your pet's hunger? Do they nibble or are they always hungry? *

It is their normal. Well. Normal, they've always been a nibbler. I've noticed an increase. I've noticed a decrease.

IF there has been a change in eating, when did you first notice this? Please type "N/A" if this does not apply. *

Please list the brand of DRY food your pet eats. How much is fed & how often? *

What brand of WET or CANNED food does your pet eat? How much is fed and how often? Type "N/A" if this does not apply. *

Does your pet eat any treats? List the brands. How many treats per day and how often are they given? Type "NONE" if this does not apply. *

Human Food/ Table Scraps: Does you pet get any? *

Yes No

IF yes, please describe what type of food, how it is cooked, and what seasonings are used (excluding salt & pepper.) Type "N/A" if this does not apply. *

Drinking: Has there been any increase or decrease with your pet's water intake? *

No, it is their normal. Yes, I've noticed an increase. Yes, I've noticed a decrease.

IF there has been a change with drinking, when did you first notice the difference? Type "N/A" if this does not apply. *

Urination: *

Volume and frequency are normal. Volume is low and frequency is low Volume is high and frequency is high Volume is high and frequency is low. Volume is low and frequency is high

IF you answered anything other than normal, when did you first notice the difference? Please note any other abnormalities (color, smell, etc.) Type "N/A" if this does not apply. *

Defecation: What consistency does your pet's bowel movement normally look like? *

Normal, tubular in form. Soft-serve ice cream Pudding-like Diarrhea/ Watery Hard & Dry

Please note any other abnormal observations about your pet's bowel movement (blood- bright or dark red, any other color or texture, difference in smell, etc.) When did you first notice these differences? Type "N/A" this does not apply. *

Has your pet had any vomiting? *

Yes No

Please describe what the vomit looked like. Include the number of times they've vomited. Type "N/A" if this does not apply. *

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

Yes No Maybe

Pain continued-- Please describe painful signs and body parts and when you first noticed them. Type "N/A" if this does not apply. *

Have you noticed your pet scratching, itching, biting or licking themselves? Select all that apply. *

None Scratching/ Itching Biting Licking

Where specifically or what body parts have these symptoms occurred? When did you first notice it? Type "N/A" if this does not apply. *

Has your pet been coughing? *

Yes No

If yes, how long have you noticed the coughing? Type "N/A" if this does not apply. *

Please describe what the cough sounds like: Is it dry, wet, like trying to get up a hairball, etc.? *

Please list any situations or environments that seem to cause the coughing. *

Has your pet been sneezing? *

Yes No

If yes, how often would you say it happens? Type "N/A" if this does not apply. *

If yes, what situations or environments seem to cause it? *

Does your pet have any allergies that you are aware of? *

No known allergies. Yes, seasonal allergies Yes, environmental allergies Yes, medication(s) allergy Yes, has had a previous vaccine reaction(s).

Allergies continued... IF you said "yes" to a medication allergy or previous vaccine reaction, please list the specifics and describe what happens. Type "N/A" if this does not apply. *

Do you provide daily dental care to your pet at home? *

No, I do not provide daily dental care at home. However, I would like to start! No, I do not provide daily dental care at home. Yes, I brush their teeth with a pet-formulated enzymatic toothpaste! Yes, I use a daily enzymatic water additive. Yes, I give them a dental chew.

Daily Dental Care continued... Please list the name of the dental product(s) your pet currently uses. Type "N/A" if this does not apply. *

Medications:

What heartworm preventative do you give your pet? *

None ProHeart 6 Injections Revolution Plus Sentinel Spectrum Other

If "other," what is the name of the product do you use? *

On what date was the heartworm prevention given last? If none given, type "NONE." *

Do you need a refill of heartworm preventative today? *

Yes No

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

None Advantix II Nexgard Revolution Plus Seresto Collar Other

If "other," please list the name of the flea and tick product. *

Please list the date the flea and tick prevention was last given. If none given, type "NONE." *

Do you need a refill of adult flea / tick preventative today? *

Yes No

Is your pet on any other medications? *

Yes No

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

Medication #1 Name & Strength *

Medication #1 Frequency: *

Do you need a refill on medication #1 today? *

Yes, please refill, if a refill is available.

Medication #2 Name & Strength: *

Medication #2 Frequency: *

Do you need a refill on medication #2 today? *

Yes, please refill, if a refill is available.

Medication #3 Name & Strength: *

Medication #3 Frequency: *

Do you need a refill on medication #3 today? *

Yes, please refill, if a refill is available.

List any additional medications/strengths and frequency given here. Please indicate if you need any refills on the below listed medications. *

Wrapping Up:

Are there any other questions or concerns you have about your pet today? *

We have a variety of programs and services here at Adair County Animal Hospital and Laser Surgery Center. Please check the provided box by any service/program you would like more information about. *

Wellness Plans Pet Insurance Vaccines & Parasite Prevention 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 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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Apply