Skip to main content
Hit enter to search or ESC to close
Home
About Us
Our Team
Hours & Location
AAHA Accreditation
What We Are Doing
Awards and Recognition
Career Opportunities
Clients
New Clients – What to Expect
Take A Tour
What Clients Say
Pet Of The Month
In Memory
Request Appointment
Refill Request
Services
Medical Services
Surgical Services
Dental Care
We Love Cats and We Are Cat Friendly
Anesthesia and Patient Monitoring
Preventive Services
Wellness and Vaccination Programs
Health Screening Tests
Nutritional Counseling
Additional Services
Products
Pet Health
Educational Articles
How-To Videos
Pet Health Checker
News
FAQs
Links
Emergency
Online store
Vet Source
Hills to Home
Purina Vet Direct
facebook
google-plus
search
PRE VISIT HISTORY CANINE
In order to address your concerns during your dog's upcoming visit, please complete this form, save and email back to the hospital no later than 24 hours before the scheduled appointment. We look forward to seeing you and your pet. Please complete one form for each dog.
Name
*
First
Last
Pet's Name
*
Date
*
Date Format: MM slash DD slash YYYY
Purpose of Upcoming Visit:
*
Exam +/- Vaccines
Illness or Injury
Medical Progress Exam
New Client
New Patient
Lab Test(s)
Radiology
Dental Procedure
Surgical Procedure
Behavioral Consult
Nutritional Consult
Telemedicine Consult
Specialist Visit (Ultrasound or Cardiac Echocardiogram)
Other
If other please explain:
*
My Dog’s Lifestyle:
*
(check all that apply)
Spends time just around the neighborhood
Goes to dog parks
Goes to Daycare
Goes to classes
Goes to a Groomer
Stays at a Boarding Facility
Goes Hiking or Camping
Travels out of Washington
If they do travel outside of Washington – Where?
*
Please Tell Us About the Food(s) You Feed Your Dog: [brand name, flavor, version, dry, can, treats etc.]
*
Current Medication(s): please list the name & how often you give; include any supplements or OTC products
*
Tell us how your dog has been since we last saw him/her
Appetite or volume of food consumed - Drop Down
*
Normal
Increased
Decreased
Appetite or volume of food consumed
*
Normal
Increased
Decreased
Water intake / thirst
*
Normal
Increased
Decreased
Urination frequency and volume
*
Normal
Increased
Decreased
Defecation frequency and volume
*
Normal
Increased
Decreased
Energy - stamina and activity
*
Normal
Increased
Decreased
Hearing
*
Normal
Increased
Decreased
Eyesight
*
Normal
Increased
Decreased
Has your dog had any of the following symptoms?
Vomiting with any frequency or repeated?
*
Yes
No
Diarrhea or change in stools?
*
Yes
No
Coughing or difficulty breathing?
*
Yes
No
Sneezing or nasal discharge?
*
Yes
No
Discharge from the eyes that is unusual?
*
Yes
No
Changes with ears, ear discharge or odor?
*
Yes
No
Skin Sores or scratching?
*
Yes
No
New or changed lumps, growths or swellings?
*
Yes
No
Limping or change in mobility?
*
Yes
No
Pain?
*
Yes
No
Behavior Change?
*
Yes
No
Please provide details to the changes you are seeing:
*
Other issues/concerns you want the doctor to address during your visit. (Some issues may need to be addressed at a separate visit)
*
Δ
Home
About Us
Our Team
Hours & Location
AAHA Accreditation
What We Are Doing
Awards and Recognition
Career Opportunities
Clients
New Clients – What to Expect
Take A Tour
What Clients Say
Pet Of The Month
In Memory
Request Appointment
Refill Request
Services
Medical Services
Surgical Services
Dental Care
We Love Cats and We Are Cat Friendly
Anesthesia and Patient Monitoring
Preventive Services
Wellness and Vaccination Programs
Health Screening Tests
Nutritional Counseling
Additional Services
Products
Pet Health
Educational Articles
How-To Videos
Pet Health Checker
News
FAQs
Links
Emergency
Online store
Vet Source
Hills to Home
Purina Vet Direct
facebook
google-plus