Hero’s Pet Clinic Client History Form Hero’s Pet Clinic Client History Form: Guardian NameAddressPhone NumberEmail AddressWho may we thank for referring you?If your pet has been seen by another veterinarian in the last 3 years, may we call for a copy of medical records?YesNoClinic and/or name(s) of VeterinarianPet NamePet AgePet BreedSpayed/Neutered?YesNoAt what age was your pet spayed/neutered?How long have you had your pet?Where did you get your pet? (from a breeder, rescue or other?)What is the reason for today’s visit?What symptoms have you noticed in your pet?Which medications does your pet take? Please indicate name, dose, frequency, and how long your pet has been taking each medicationDoes your pet receive regular vaccinations?YesNoWhat was the date of most recent vaccines?Does your pet take Heartworm Prevention?YesNoIf so, what brand do you use and how often do you give it?Does your pet receive any flea and/or tick prevention?YesNoIf so, what brand do you use and how often do you give it?If there have been any behavioral changes please describe them:If there have been any changes in stools/defecation or urination habits please describe:If there have been changes in drinking /eating habits please describe:Does your pet rub at its mouth, drool more than usual, or seem painful in their mouth?YesNoWhen did your pet last have any dental work done?If your pet has been itchy please describe where on the body and if there is a time of year that itching is worse:Does your pet lick or chew on themselves?YesNoIf yes, what part of the body?Describe any food sensitivities your pet may have:Has your pet been coughing?YesNoSneezing?YesNoIs it getting worse, better, or staying the same?If your pet has been limping please describe which leg and for how long:Describe any changes in your pet's energy levels:Describe any anxious behaviors your pet may have:What brand of food do you currently feed your pet?If you have fed this food for less than 3 months, what other brands have to given to your pet in this time?How much do you feed your pet per meal?do you weigh your food with a scale or measure it with a cup?ScaleCupHow many times per day do you feed your pet?What type of chews does your pet get and how often?What type of treats does your pet get and how often?What people food do you or anyone in your family give to your pet?Your pet's weight?OverweightUnderweightIdeal weightWhat are your main considerations when choosing products for your pet?CostQualityCompany EthicsPet's PreferenceOtherWhat is your ideal food, treat and chew budget you prefer for your pet per month?Which supplements does your pet take? Please indicate name, dose, frequency, and how long your pet has been taking each supplementWhat type of exercise does your pet get? How often? How long?Do you do competitive activities with your pet(shows/agility/fly ball, etc..)? How often are competitions? How frequently does training occur?What is your pet’s daily routine during the week?What is your pet’s daily routine during the weekend?How is your pet cared for when you are out of town?BoardingPet SitterIn HomeOtherDoes your pet like to go for walks?YesNoDoes your pet like car rides?YesNoIs there anything else we need to know about your pet?
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