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(262) 843-4271
26851 75th Street Salem, Wisconsin
westoshaveterinaryhospital@gmail.com
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Pet Health Form
Client Name
First
Last
Pet Name
First
Species (dog or cat)
Main reason for visit
Previous medical problems we should know about:
Current medications/supplements (name of medication and how much/how often you are giving):
Do you need a refill?
Yes
No
What kind of food do you feed?
How much per day?
Which heartworm prevention is your pet currently on?
Do you need a refill?
Yes
No
Which flea and tick prevention is your pet currently on?
Do you need a refill?
Yes
No
How has your pet’s appetite been?
Normal
Increased Appetite
Decreased Appetite
Not Eating At All
How has your pet’s water intake been?
Normal
Increased Drinking
Decreased Drinking
Not Drinking At All
Has your pet been vomiting? (if so when did it start, how often, and when was the last time)
Has your pet had any diarrhea? (if so when did it start, any blood or mucous, describe consistency)
Has your pet been:
Select All
Coughing
Sneezing
Had a Runny Nose
If your pet has had a runny nose, for how long?
Has your pet had any of the following eye problems?
Select All
Discharge
Squinting
Redness
Rubbing
When did it start?
Which eye? (or both)
Has your pet been scratching at their ears?
Any Odor?
Shaking Head?
Has your pet had any skin problems?
Has your pet had any skin problems?
If so, please check any of the following:
Scratching or Licking?
Odor?
Hair Loss?
Sores?
Has your pet been urinating normally and outside/in litterbox (cat)?
Any history of seizures?
How Often?
How long?
Any Growths or Lumps?
Location?
How long?
Has your pet been limping? Which leg?
Left
Right
Both
How long?
Any known Injuries?
Do you have any other pets in the house?
Dogs
Cats
Other
If yes, how many of each?
Any other concerns or questions for the Doctor today?
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Home
About Us
Our Team
Location & Hours
Promotions
Careers
New Clients
What To Expect
Take A Tour
New Client Registration Form
Greyhound Adoptions
My Pet
Services
Wellness and Vaccination
Preventive Services
Medical Services
Surgical Services
Laser Therapy
Anesthesia and Patient Monitoring
Nutritional Counseling
Health Screening Tests
Pet Supplies
Additional Services
Pet Health
Online Forms
Surgery/Dental Check-In Form
Pet Health Form
Client Visit Survey
Make An Appointment
Nail Trim Desensitization
Pet Health Library
Pet Health Checker
How-To Videos
Pet Health News
Helpful Links
Pet Food Recalls
Product Recalls
Pet Insurance
Payment Options
Online Pharmacy
Online Pharmacy
Purina Vet Direct
Contact
Make An Appointment
Emergency Care
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