Pet Health Form

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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?
- 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!

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Location

Westosha Veterinary Hospital
26851 75th Street
Salem, Wisconsin, 53168

We Are a Certified Cat Friendly Practice by the American Association of Feline Practitioners!

Location Hours

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 – 1:00pm
Sunday	Closed

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Pet Health Form

Pet Health Form

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In the News

Thanksgiving Foods – What’s Okay to Share With Pets?

Location

Westosha Veterinary Hospital

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