Patient History Form

Phone number you can be reached at today (include area code):*

Date:*

Name:*

First Last

Pet’s Name:*

Please describe the problem(s):*

How long has the problem existed?*

Appetite:*

Normal
Increased
Decreased

Activity:*

Normal
Increased
Decreased

Urination:*

Normal
Increased
Decreased

Water Drinking:*

Normal
Increased
Decreased

Bowel Movements:*

Normal
Diarrhea
Constipation

Coughing?*

Yes
No

Labored Breathing?*

Yes
No

Vomiting?*

Yes
No

If yes, approximately how many times per day?

Has your pet been on any medications previously for this condition?*

Yes
No

If yes, please specify the medication:

Did it help?

Yes
No

List all medications that your pet is now receiving:

Are your pet’s vaccines up to date through AHC?*

Yes
No

If not, where were they given?

Any other useful information?

Consent

I grant authority for the attending veterinarian to administer sedation or general anesthesia to the above described pet if it is deemed necessary in his/her professional judgment. I understand the related risks involved with sedation or general anesthesia. It is further understood that the veterinarian will attempt to contact me prior to administration of sedation or general anesthesia.