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Canine Health History Form

Client(Required)

Email(Required)

Patient Profile

Name(Required)

Breed(Required)

Weight(Required)

D.O.B.(Required)

Type

Sex(Required)

Male

Female

Neutered

Spayed

Please help us provide the best and most personalized care for your pet by responding to the following questions prior to pet’s scheduled appointment. Thank you!

Environment

What is your pet outdoor environment like? (Please select all that apply)

Wooded areas, hiking

Standing water, lakes, streams, etc.

Grass, neighbourhood, urban

Farm, rural, working dog

Does your pet go to any of the following? (Please select all that apply)

Boarding or Doggy Daycare

Grooming

Dog Parks

Pet Stores

Other (interacting with friends/family member dogs, etc.)

Health Overview

Have you noticed any issues/problems with your pet? (this can include changes in behavior, sleep or play)(Required)

Yes (Please describe below)

If answered yes above(Required)

Have you noticed any problems with pet getting around/mobility issues?(Required)

Yes, pet is having mobility issues that I want to talk with the nurse/doctor about

What prescription medications, supplements and/or OTC medications does pet receive?

Preventatives & Parasites

Do you give heartworm/flea/tick prevention every month all year round?(Required)

Every month, all year round

Seasonally, during the warm months

My pet does not receive heartworm/flea/tick prevention

What brand(s) of heartworm and flea/tick prevention do you give?

Simparica Trio

Credilio (or Credilio Quattro)

Interceptor

Trifexis

Nextguard | Heartguard

Simparica

Revolution

Other

Brand Name

When did receive their last dosage of heartworm/flea/tick prevention?

Within the last 30 days

Within the last 3 months

I’m not sure

What medication(s), monthly preventative(s), or prescription food do you need refilled today?

Just Prevention Medication

Monthly Medications

Anxiety Medications

Specific Medications

Medications details

Have you seen any fleas or ticks or any parasites in stool?(Required)

Yes

Lifestyle & Diet

What type of food do you feed? What is your feeding routine? (amount offered, how many times daily)?

Is your pet eating and drinking normal amounts? If not, what changes have you noticed?(Required)

They are drinking and eating normally.

They have had some concerning changes to eating or drinking habits.

What changes with your pet eating or drinking have you noticed?(Required)

How do you feel about weight / body condition?(Required)

Perfect!

Too thin

Overweight

I’m not sure, help me assess!

Have you noticed any changes in urination and defecation habits (frequency of urination or defecation, diarrhea or excessively hard stool, etc.)?(Required)

Yes

I’m not sure

Has your pet had any vomiting, regurgitation or diarrhea?(Required)

Yes, occasionally and I’m not worried about it

Yes, frequently and I want to talk to my nurse/doctor more about this

Physical Health Check

Have you noticed any lumps or bumps?

Yes and it/they are the same as during the last vet visit

Yes and it/they have changed; I want to talk to my doctor/nurse about this

Has your pet been coughing or sneezing more than normal?(Required)

No, no abnormal coughing nor sneezing

Yes, coughing and sneezing more than normal

Yes, coughing more than normal

Yes, sneezing more than normal

Is your pet scratching or chewing at themselves or doing any excessive head shaking? (Please select all that apply)(Required)

No, none of these

Yes, scratching more than normal

Yes, chewing/licking more than normal

Yes, head shaking more than normal

We recommend screening yearly blood and fecal testing. Do you authorize this labwork if it is due?(Required)

Yes, please do all recommended blood and fecal testing for my pet.

I’m not sure, I need more information from my nurse/doctor before making a decision.

No, I decline the recommended blood and fecal testing.

Does your pet need any additional services while with us today?

Nail Trim

Other

Please let your nurse or assistant know(Required)

Find Us

Make an Appointment

Online Pharmacy

What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make an Appointment

Where family pets find loving care

Make an Appointment

317-344-0906

11812 Sylo Crossing,
Zionsville, IN 46077

Home
About Us
Services
Indy Pet CORE
Urgent Care
Online Pharmacy
Contact Us

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Canine Health History Form

Patient Profile

Environment

Health Overview

Preventatives & Parasites

Lifestyle & Diet

Physical Health Check

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care