Patient Health QuestionnairePlease answer the following questions about your pet's medical history. Bring this form with you to your next appointment. Attach any previous medical records or submit the Medical Records Release Form to have your pet's records transferred to our hospital.Client Name: First Last Pet's Name:Reason for today's visit / presenting health concern?Have you noticed any changes (increase or decrease) in the following? Water consumption, thirstYesNoCommentsBody weight / muscle massYesNoCommentsUrinary habits or accidentsYesNoCommentsDefecation (bowel movement) or accidentsYesNoCommentsAppetite, beggingYesNoCommentsAggression, personality changesYesNoCommentsActivity, exercise, lethargyYesNoCommentsLimpingYesNoCommentsHearingYesNoCommentsJoint, back painYesNoCommentsVisionYesNoCommentsBarking, crying out, vocalizingYesNoCommentsSeizuresYesNoCommentsCoughing, wheezingYesNoCommentsVomitingYesNoCommentsDiarrheaYesNoCommentsSneezingYesNoCommentsSlow to get up after restYesNoCommentsItchingYesNoCommentsHair loss, flakingYesNoCommentsNew masses, growths, lumpsYesNoCommentsDischarge from eyes, nose, mouthYesNoCommentsDischarge from prepuce, vulvaYesNoCommentsSleep patternsYesNoCommentsOther painYesNoCommentsHow long have you owned this pet?Where did you obtain this pet? Outside of this region / state?Have you travelled recently with the pet?Is the pet on heartworm preventive? What brand?Is the pet on flea / tick preventive? What brand?Have the pet been exposed to fleas or ticks?Is the pet used for hunting or taken on camping trips?Is the pet used for breeding? Last date of breeding / heat cycle?Any prior illnesses?Any non-elective surgeries?Has the pet ever had an allergic reaction to vaccine or any other medication?Does the pet eat anything besides dog or cat food?Additional comments or concerns
