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?

Our Address

26851 75th Street
Salem, Wisconsin 53168

Phone: (262) 843-4271
Fax: (262) 586-5163
westoshaveterinaryhospital@gmail.com

Our Hours

Monday- Thursday:
8:00 am – 8:00 pm
Friday: 8:00 am – 5:00 pm
Saturday: 8:00 am – 12:00 pm
Sunday: Closed