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?

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?

Please call us at (262) 843-4271 when you arrive. Please remain in your car. Please put your face mask on when we come out to get your pet. Thank you for your patience during this challenging time!

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

Contact Us

26851 75th Street
Salem, WI
53168

Phone: (262) 843-4271
Fax: (262) 586-5163
Email Us

Pet Health Form

Pet Health Form

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Location

Westosha Veterinary Hospital

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Pet Health Form

Pet Health Form

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In the News

Do any of these pet owner stereotypes describe you?

Location

Westosha Veterinary Hospital

ePet Health