Patient History Form

  • Patient Name*

  • Reason for Visit*

  • Behavior

    Normal/No Change Quiet Lethargic Anxious Aggressive Hiding Other:
  • Appetite

    Normal Increased Decreased None
  • Water Intake

    Normal Increased Decreased None
  • Coughing

    Yes No Unknown
  • If yes, describe

  • Sneezing:

    Yes No Unknown
  • Vomiting:

    Yes No Unknown
  • If yes, describe

  • Defecation

    Normal Soft Hard Diarrhea None Unknown
  • Urination:

    Normal Increased Decreased None Inappropriate
  • Painful:

    Yes No Unknown
  • Difficulty with stairs or on/off furniture:

    Yes No
  • Difficulty moving from laying to sitting position:

    Yes No
  • Bad Breath:

    Yes No
  • Drooling:

    Yes No
  • Dental Chews/Brush Teeth:

    Yes No
  • Current Diet (Brand/Frequency):

  • Table Scraps:

    Yes No
  • Heartworm Prevention:

    Yes No
  • If yes, product name:

  • Flea/Tick Prevention:

    Yes No
  • If yes, product name:

  • Current medications (dosage and frequency):

  • Allergies (Medications/vaccines/food):

    None known Yes
  • If yes, please list

  • Exposure (Outdoors):

    Indoor Only Fenced Yard Indoor/Outdoor Mostly Outdoor
  • Exposure (Other):

    Boarding/Daycare Groom Obedience Class Dog Parks None
  • Other Pets In Household (please list names):

  • Other Comments:

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PETSimonials

North Valley Pet Hospital employs such a tremendous team that does not overlook any details. Personable, reliable, and efficient are words that describe North Valley Pet Hospital. I would not trust another establishment to take care of my fur babies.