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Patient History Form
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* Indicates required question
First Name
Your answer
Last Name
Your answer
Best Number to reach you at during the visit
Your answer
Email
Your answer
Date
MM
/
DD
/
YYYY
Pet's Name
Your answer
What type of visit do you prefer?
Curbside
In Person
Clear selection
If Curbside - How would you like us to communicate with you?
Tele Tails Video Visit
Phone Call
Clear selection
Reason for visit: (check all that apply) *
*
Wellness
Recheck
Illness
Injury
Other:
Required
Please list any other problems or symptoms present at this time
Please briefly describe any major illnesses, surgery or other problems that occurred in the past
Your answer
Please describe your pet’s diet (specify the brand, canned or dry and the daily amount)
Your answer
List any current medications and/or supplements
Your answer
Is your pet on monthly flea/tick and/or heartworm prevention? Which ones?
Your answer
Pick one of these 5 descriptions that best describes your pet’s personality
Easy going, loves everyone, laid back, easily satisfied, patient, social, slow reaction to strangers
Fearful, quiet, independent, a one person pet, shy, smart, runs away from strangers
Well-behaved, obedient, likes a routine, problem solver, ignores strangers
Dominant, very active, moves fast, competitive, stubborn, barks at strangers
Excitable, hard to calm down, likes to be center of attention, mischievous, wags tail at strangers
Clear selection
If this is a follow up visit, describe what has changed since last treatment; list what has improved and what has deteriorated
Your answer
Are there any concerns for the following: (check all that apply)
Increase in appetite
Decrease in appetite
Increase in drinking
Decrease in drinking
Weight Loss
Weight Gain
Itching/Scratching
Shaking Head
Bad Breath
Vomiting
Diarrhea
Urination Issues
Excessive Sleeping
Scooting
Difficulty Rising
Skin Masses (explain below)
Car Sickness
Behavioral Problem
Other:
When did the problem(s) start?
Your answer
Have the symptoms worsened, improved, or stayed the same since you first noticed them?
No change
Worsened
Improved
Clear selection
Has your pet experienced this problem in the past? *
*
Yes
No
Is your pet on any medications? *
*
Yes
No
Have there been any changes in appetite? *
*
Increased
Decreased
No change
If there has, for how long? Please elaborate. *
*
Your answer
Any increase or decrease in water consumption? *
*
Increased
Decreased
No change
Any change in bowel movements? *
*
Yes
No
Unsure
Does your pet spend time outside, even for walks or in the yard? *
*
Yes
No
<For Dogs only> Does your dog come into contact with other dogs? Please check all that apply *
Boarding
Grooming
Dog Parks
None of the above
Other:
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