Patient History Questionnaire

Patient Name:*

Client Name:*

Date of Appointment:

Doctor Name:

Please list any past major surgeries or illnesses including date periods:

Please list any current medications, including the dose and frequency of administration: Example: Prednisone 5 mg 1 tablet once daily in morning

Pet’s Diet:

Does your pet go outside?*

When your pet goes outside is it:

Has your pet traveled outside of New England?*

When was their travel?

Where was their travel?

Date of last Rabies vaccination (if known):

Was it 3 year or 1 year?

Please give us some information on your pet’s current medical or surgical problem:*

When did you first notice this:

Please describe

Does your pet have any known allergies:

Please list known allergies

Has your pet had any adverse reactions to medications and/or anesthesia?

Please list adverse reactions to medications and/or anethesia

Please list any special concerns you may have: