Dr. Naidoo Ultrasound Patient History Form - Frontier Veterinary Hospital, P.C.

Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Age/Date of Birth *

Breed *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Primary Care Veterinarian *

How long have you owned your pet? *

How did you obtain your pet? *

What are your main concerns for your pet's health? What symptoms are you seeing at home that worry you? *

How long have these concerns been present? *

Does your pet spend time primarily: *

Indoors
Outdoors
Both

Do you have a multiple pet household? *

Is your pet having vomiting or diarrhea? *

Yes
No

If yes, please describe the appearance (blood, mucus, bile, consistency, etc.) and frequency. *

Is your pet having breathing difficulties or coughing? *

Yes
No

If yes, please describe (panting, noisy breathing, wet or honking cough, etc.). *

Is your pet having sneezing or nasal discharge? *

Yes
No

If yes, please describe the frequency and appearance. *

What diet does your pet eat? (brand and type, main ingredients if known). *

Is your pet's appetite normal? *

Yes
No

If not, please describe whether appetite is increased or decreased. *

Is your pet drinking a normal amount of water? *

Yes
No

If not, please describe whether the water intake is increased or decreased. *

Is your pet urinating normal volumes? *

Yes
No

If not, please describe whether urine volume is increased or decreased. *

Is your pet urinating more frequently? *

Yes
No

Is your pet having any difficult or painful urinations? *

Yes
No

Has your pet lost weight recently? *

Yes
No

Does your pet have a normal activity level? *

Yes
No

If not, please describe. *

Is your pet's behavior normal? *

Yes
No

If not, please describe. *

Have you noted any abnormal bleeding (from the gums or nose, in the urine/feces, etc)? *

Yes
No

Has your pet traveled outside the Pacific Northwest in the past year? *

Yes
No

Is your pet up-to-date on routine vaccinations? *

Yes
No

Does you pet receive monthly heartworm and flea preventatives? *

Yes
No

Have you seen a tick attached to your pet in the past six months? *

Yes
No

What medications and/or supplements (including herbs and vitamins) are you giving your pet? If available, please provide the doses.

Does your pet have any previously diagnosed medical problems?