Patient History Form

Save time during your next appointment! Complete your required forms online before your visit.

Patient History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Personal Information

Owner's name *

First

Last

Who will be present for the animal’s visit? *

Phone number *

Email address *

**Your email address is strictly used for internal purposes and for communication directly with you. We send out your pet’s appointment notes/reminders, revised policies, internal promotions that would apply to you, inclement weather updates, estimates for surgical/medical services as well as surveys on how to improve our services.

Farm or business name (If Applicable)

Animal's name *

Animal’s species and life stage *

Adult and/or Senior Dog
Puppy
Adult and/or Senior Cat
Kitten
Horse

What is the reason for your animal’s appointment? Check all that apply *

Wellness/Vaccination
Diarrhea
Vomiting
Skin Concern
Ear Concern
Eye Concern
Urinary Concern
Limb Soreness/Lameness
Pain
Lump
Sick Animal/Other

What is the reason for your animal’s appointment? Check all that apply *

Wellness/Vaccination
Limb Soreness/Lameness
Sick Animal/Other

Have there been any changes to your address, phone number, email, animals’ location, etc.? *

Please specify: *

What is your main concern today? *

How long have you noticed a change? *

Any current medications and/or supplements? *

Indicate N/A if not applicable

Have there been any changes in appetite? *

Please specify: *

Have there been any changes in thirst? *

Please specify: *

What is their feeding regimen? *

Has the animal been vaccinated within the last year? *

Please specify: *

Has the animal been dewormed in the last year? *

Yes
No
Unknown

Please specify which dewormer was used: *

Would you like us to provide dewormer for your animal at this appointment? *

Yes
No
Unknown

Please specify if you have a preference: *

Has this animal had their teeth floated within the last 2 years (if applicable)?

Yes
No
Unknown

Please specify when and if there were any concerns noted at that time: *

Are there any other health concerns you would like addressed at this appointment? *

Please specify: *

Have there been any changes to your address, phone number, email, animals’ location, etc.? *

Please specify: *

Is there any obvious swelling/heat? *

Has your animal been on stall rest? *

Any current medications and/or supplements? *

Indicate N/A if not applicable

Has there been any previous vaccine reactions or reactions to other medications? *

Yes
No
Unknown

Please specify: *

Does your animal live in a tick prominent area? *

Yes
No
Unknown

Has the animal been vaccinated within the last year? *

Please specify which vaccines were given and when: *

If recommended, would you like to proceed with x-rays, ultrasound and/or local nerve blocks? *

Are there any other health concerns you would like addressed at this appointment? *

Please specify: *

Have there been any changes to your address, phone number, email, animals’ location, etc.? *

Please specify: *

What is your main concern today? *

Indicate N/A if not applicable

Any current medications and/or supplements? *

Indicate N/A if not applicable

Has there been any previous vaccine reactions or reactions to other medications? *

Yes
No
Unknown

Please specify: *

Has the animal been vaccinated within the last year? *

Please specify which vaccines were given and when: *

Which vaccines are you interested in your animal receiving this year? *

Indicate N/A if not applicable

Have there been any changes or concerns related to bowel movements? *

Please specify: *

Have there been any changes or concerns related to urination? *

Please specify: *

Have there been any changes in appetite? *

Please specify: *

Have there been any changes in thirst? *

Please specify: *

Any excessive or concerning coughing/sneezing/discharge from nose? *

Please specify: *

Any limping/stiffness? *

Please specify: *

Any lumps noticed? *

Please specify: *

Any recent or noticeable weight loss? *

Has the animal been dewormed in the last year? *

Yes
No
Unknown

Please specify which dewormer was used: *

Would you like us to provide dewormer for your animal at this appointment? *

Yes
No
Unknown

Please specify if you have a preference: *

Has this animal had their teeth floated within the last 2 years (if applicable)?

Yes
No
Unknown

Please specify when and if there were any concerns noted at that time: *

Any plans on taking the animal off their typical property? *

Does your animal live in a tick prominent area? *

Yes
No
Unknown

When did the pain/lameness start? *

What limb do you think the pain is coming from? *

Is the pain constant or does it get worse with exercise? *

Pain is constant
Pain gets worse with exercise
Not sure

Does the pain seem to be worse after lying down or sitting still for a period of time? *

Is there a known injury associated with this pain? *

Yes
No
Unknown

Please specify: *

When did the pain/lameness start? *

What limb is the pain coming from? *

Is the pain constant or does it get worse with exercise? *

Pain is constant
Pain gets worse with exercise
Not sure

Does the pain seem to be worse after lying down or sitting still for a period of time? *

Is there a known injury associated with this pain? *

Is there any other history associated with this issue that you would like your veterinarian to know about? *

If yes, please elaborate: *

Please describe the pain your pet is experiencing: *

Please describe location(s) and history of lump(s). *

Please upload any photo(s) of the lump(s).

Click or drag files to this area to upload. You can upload up to 5 files.

Puppy wellness exam history questions

Is this your puppy's first visit with us? *

Puppy basics

From where did you adopt your puppy? *

Has there been any previous vaccination or deworming? *

Yes
No
Unsure

Dates and products used: *

Any plans for obedience training or puppy classes? *

Yes
No
Undecided, would like to discuss

How is house training coming along (i.e. fecal or urinary accidents common or not)? *

Are you crate training? *

Yes
No
Undecided, would like to discuss

How is everyone adjusting to the new puppy in the household? *

Any thoughts on pet insurance? *

Kitten wellness exam history questions

Is this your kitten's first visit with us? *

Kitten basics

From where did you adopt your kitten? *

Has there been any previous vaccination or deworming? *

Yes
No
Unsure

Dates and products used: *

How is house training/litter box training coming along (i.e. fecal or urinary accidents common or not)? *

How is everyone adjusting to the new kitten in the household? *

Are thoughts on pet insurance? *

Adult to senior dog wellness exam history questions

What is your main concern today? *

Indicate N/A if not applicable.

Any current medications and/or supplements? *

Indicate N/A if not applicable.

Any plans on boarding, grooming, attending doggy day care, the dog park or travelling (including to the lake) with your dog? *

Indicate N/A if not applicable.

What kind of food are you feeding, including treats? How much? *

Is heartworm prevention medication up to date or have there been any missed doses? *

Has there been any previous vaccine reactions or reactions to other medications? *

Yes
No
Unknown

Please specify. *

Have there been any changes or concerns related to bowel movements? *

Please specify. *

Have there been any changes or concerns related to urination? *

Please specify. *

Adult to senior cat wellness exam history questions

What is your main concern today? *

Indicate N/A if not applicable.

Any current medications and/or supplements? *

Indicate N/A if not applicable.

What kind of food are you feeding, including treats? How much? *

How many bowel movements a day? *

How many episodes of urination? *

(Provide your best guess)

Has there been any previous vaccine reactions or reactions to other medications? *

Yes
No
Unknown

Please specify. *

Have there been any changes or concerns related to bowel movements? *

Please specify. *

Have there been any changes or concerns related to urination? *

Please specify. *

Has heartworm prevention been started? *

Please indicate time of year started. *

Have there been any changes in appetite? *

Please specify. *

Have there been any changes in thirst? *

Please specify. *

Any general concerns?

Any excessive or concerning coughing/sneezing? *

Please specify. *

Any excessive or concerning itching and scratching? *

Please specify. *

Any limping/stiffness? *

Any lumps noticed? *

Any recent or noticeable weight loss? *

Any behavioural problems/concerns? *

Please specify. *

Have there been any changes in appetite? *

Please specify. *

Have there been any changes in thirst? *

Please specify. *

Any excessive or concerning coughing/sneezing? *

Please specify. *

Any excessive or concerning itching and scratching? *

Please specify. *

Any limping/stiffness (having trouble jumping up onto things, climbing stairs, etc)? *

Any lumps noticed? *

Any recent or noticeable weight loss? *

Any behavioural problems/concerns? *

Does your cat spend time outdoors? *

Diarrhea concern history questions

How long have they had diarrhea? *

Please describe appearance: *

Bloody
Mucoid
Watery
Normal color but different consistency
Other

Please specify. *

How much and how frequent? *

What is their appetite like? *

Decreased
Increased
Normal

Have you tried a bland diet? *

Are they on a heartworm/parasite prevention program? *

Is there any vomiting? *

Is there any history of eating garbage, table food, toys? *

Please specify. *

Has there been a change in environment, boarding or other stress? *

Please specify. *

Any current medications or supplements? *

Please specify. *

Are there any other concerns you would like to bring up with the doctor?

Vomiting concern history questions

How long have you noticed a change? *

Is there a particular time of day/night it occurs? If so, what time? *

What kind of food are you feeding? *

Please also specify frequency and amount.

Are they vomiting food or phlegm/bile? *

Food
Phlegm/bile
Other

Please specify. *

Do they eat food quickly? *

How long after eating do they vomit? *

Is there any history of recently eating garbage/table scraps/toys/strings/other? *

Please specify. *

Is their normal activity present? *

Is their normal appetite present? *

Have you tried a bland diet? *

Any current medications or supplements?

Please specify. *

Are there any other concerns/problems for the doctor to address?

Skin concern history questions

How long have you noticed a change? *

Are they scratching/itchy? *

Rate itchiness 1-10: *

Are they chewing/licking the lesion or their feet/tail? *

Any recent swimming/bathing? *

Odour and/or discharge noted in the ears? *

Any recent changes in diet? *

What diet is generally fed? *

Is there a history of skin infections itching? *

Any seasonality noted with previous infections (if applicable)? *

Are they on a heartworm/parasite prevention program? *

Have they shown signs of any fleas or other parasites? *

Does the lesion appear to be spreading or increasing in number? *

Have they been given any medications either orally or topically today or recently? *

Please provide details. *

Are there any other animals or people in the household who seem to be affected as well (itchiness and/or rashes)? *

Are there any other concerns/problems for the doctor to address?

Ear concern history questions

When did you first notice clinical signs of the ear infection? *

Have you observed odour and/or discharge from the ear(s)? *

Any rashes or irritation (itchiness) noted elsewhere on the body? *

Have they been swimming or have they been bathed recently? *

Do they have a history of ear infections? *

Does there seem to be a seasonality noted with previous infections (if applicable)? *

Have they been given any medications either orally or topically today or recently? *

Please provide details. *

Any recent changes in diet? *

What diet is generally fed? *

Eye concern history questions

What is the duration of the problem? *

Still eating and drinking? *

Any travel to Lake of the Woods or areas known to have blastomycosis? *

Yes
No
Unsure

Any current medications or supplements? *

Please specify. *

Any other health concerns? *

Describe what you have seen/found. *

Urinary concern history questions

How long have you noticed a change? *

Are they unable to urinate, or is there straining with no success? *

Is the urine a normal color, amount, and frequency? *

Do they have control over urination, or does it happen without them knowing it? *

They have control.
It happens without them knowing it.

Has there been a change in diet? *

What food is being fed and how much/frequency? *

Are they eating/drinking like normal with normal activity? *

Are any of their urination habits different (i.e. out of their box, in the house)? *

Please specify. *

Any current medications or supplements?

Please specify. *

Are there any other concerns/problems for the doctor to address?

Would you like to pick up your pet’s tick and heartworm prevention at your pet’s appointment?

In our area, tick/flea prevention is recommended from April to November or when temperatures are above 0°C, which can occur beginning in March.

Heartworm prevention is recommended from June 1st to the end of November when temperatures reach averages of 10°C.

Would you like a 4DX test completed at your pet’s appointment today?

Yes
No
I would like to learn more about this test before deciding

A 4DX test is a powerful screening tool used to evaluate the health of your dog in preparation for heartworm and tick season. In ten minutes and with only four drops of blood, this test detects exposure to diseases transmitted by mosquitos and ticks including heartworm (mosquitoes), lyme, anaplasma and ehrlichia (ticks). All four diseases are prevalent in manitoba.

the special connection you have with your senior pet. As your dedicated veterinary team, we're here to provide the best care for your beloved companions. Our annual Screening Bundles are designed with the well-being of senior pets in mind, typically those aged 8 years or older. These bundles are especially helpful for pets without current acute or chronic health issues.

Our Screening bundle without Ultrasound is a comprehensive package that helps establish your pet's baseline health. It can catch early problems before they become serious. This bundle includes a complete blood count (CBC), chemistry panel, electrolytes panel, T4, SDMA, and urinalysis (including cystocentesis if needed). Choosing this bundle for your pet costs $359.66.

For a more thorough evaluation, our Screening bundle with ultrasound includes all the tests mentioned above, plus an abdominal screening ultrasound performed by one of our experienced veterinarians. This comprehensive bundle costs $539.29. Keep in mind that preparation, including fasting, is necessary for this procedure, so a separate visit may be required.

Our goal is to give you time to review these options before your pet's wellness appointment. Your senior pet's well-being and comfort are our top priorities, and we're here to help you make informed decisions about their care. By bundling these tests with our screening bundles, you will save on average $65 compared to the price of these tests individually.

If you are interested in having one of these bundles performed for your pet at your upcoming visit, please note this within the What other procedures would you like performed on your pet during your appointment? field below. We appreciate your trust in us to care for your senior pet's health, and we look forward to providing the best possible care for your cherished companion.

What other procedures would you like performed on your animal during your appointment?

Are there any medications/supplements you wish to receive?

Optional: Specify which products and how much of each.

Phone

Patient History Form