Name *

First

Last

Phone *

Email *

Pet's Name *

Reason for Visit *

Is your pet currently taking any medications, vitamins, or supplements? *

Yes
No

Please list all medications, vitamins, or supplements (name, dosage, and frequency) below: *

Has your pet every been hospitalized for an illness or injury? *

Yes
No

If 'Yes', please explain (when, where, and why). If not applicable, please put 'N/A': *

Has your pet every had any of the below surgeries (please check all that apply)? *

Spay/Neuter
Dental Cleaning/Extractions - Complete Oral Health Exam and Treatment (COHAT)
Orthopedic (Fractue, Cranial Cruciate Ligament (CCL), Medially Luxating Patella (MLP), Intervertebral Disk Disease (IVDD), other
Wounds, Lacerations or Abscesses
Other
None of the above

If 'Other', please specify: *

Is your pet eating normally? *

Yes
No

How much is your pet eating? *

Half of their normal amount
Eating nothing
Picky
Normal Amount

Please describe the change in appetite (if any). If not applicable, please put 'N/A': *

Has there been a change in the amount of water consumption? *

Drinking more
Drinking less
Not drinking at all
No change

How often does your pet defecate (poop) daily? *

1 - 2 times daily
More than 3 times daily

Fecal Score *

Does your pet's poop contain (please check all that apply) *

Is your pet vomiting? *

Yes
No

If your pet has been vomiting, when did it begin? If not applicable, please put 'N/A': *

What is your pet vomiting (digested food, undigested food, bile, foam, grass, toys/rocks/other objects, etc.)? If not applicable, please put 'N/A': *

Any pattern to vomiting (every morning, evening, after eating, car rides, etc.)? If not applicable, please put 'N/A': *

Please describe your pet's current diet: *

Any change of diet? *

Yes
No

If 'Yes', please explain. If not applicable, please put 'N/A': *

Has your pet ingested any of the following (please check all that apply)? *

Is your pet coughing? *

Yes
No

If 'Yes', please explain: *

How often has your pet been coughing? If not applicable, please put 'N/A': *

Does something make the coughing worse? If not applicable, please put 'N/A': *

Is your pet panting more? *

Yes
No

Is your pet having any labored breathing? *

Yes
No

Is your pet sneezing? *

Yes
No

Any nasal discharge? *

Yes
No

Does your pet snore or sound congested? *

Yes
No

Does your pet have any of the below ear problems? *

If your pet is suffering from any of the ear problems above, please describe. If not applicable, please put 'N/A': *

Has your pet had problems with its ears in the past? *

Yes
No

Which ear has your pet had problems with in the past? *

Left
Right
Both

Has your pet experienced any of the following (please check all that apply)? *

If your pet is itching, where is your pet itching? If not applicable, please put 'N/A': *

On a scale of 1-10 (10 being the most severe), how severe is the itching? If not applicable, please put 'N/A': *

Where is the stiffness occurring? If not applicable, please put 'N/A': *

If your pet has issues with scooting, itching, stiffness, licking, or limping, please describe further. If not applicable, please put 'N/A': *

Which leg is your pet limping on? If not applicable, please put 'N/A': *

When did the limping begin? If not applicable, please put 'N/A': *

Any known injury or cause? If not applicable, please put 'N/A': *

Does your pet go to any of the following places (please check all that apply): *

Has your pet traveled out of the county in last 6 months? *

Yes
No

Has your pet had allergic reactions to any of the following (please check all that apply): *

Please list all medications that your pet has had an allergic reaction to: *

Please list all vaccinations that your pet has had an allergic reaction to: *

If your pet has had an allergic reaction to something other than medications, vaccinations, or a bee sting, please specify. If not applicable, please put 'N/A': *

Is your pet aggressive with people? *

Yes
No

Is your pet aggressive with other animals? *

Dogs
Cats
Both
None of the Above

Has your pet shown fearful/scared behavior? *

Yes
No

If 'Yes', please explain. If not applicable, please put 'N/A': *

Has your pet shown shyness/hiding? *

Yes
No

If 'Yes', please explain. If not applicable, please put 'N/A': *

Has your pet nipped or bitten anyone in the past? *

Yes
No

If 'Yes', please describe circumstances surrounding the bite/nip incident. If not applicable, please put 'N/A': *

Has your pet bitten anyone in past 10 days? *

Yes
No

Patient Health History Questionnaire

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Quality care and reliable service

We practice appreciation and gratitude daily at Impett Veterinary.

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