Patient History Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.BreedName of PatientDateSexColour/MarkingsWeightAgeMy pet is a:working animalshow animalbreeding animalhouse petIs he/she an indoor animal?If outdoor, how long?If outdoor, supervised?What kind of shelter does your pet have?How often is your pet groomed and who does it?Do you use any shampoos? If so what kind?Do you use any flea powders, mousse or sprays?Where did you obtain your pet?Pet storeSPCABreederStreet Cat RescueKijijiOther rescue groupOtherWhen did you obtain your pet?Do you know where s/he was born and raised?Did it have several owners?When was s/he spayed/neutered?Have there been any problems during anaesthesia or surgery?Has your pet ever had a litter or sired one?What as the litter size?Any problems during delivery?Do you know the health of parents, siblings, offspring?Do you have any other pets?What brand of food do you feed your animal and how often?Does your pet get any preventative medication likeInterceptorProgramSentinelBravectoAny other dewormerAny over the counter drugs?Any supplements or homeopathic remedies?Has your pet ever had a flea problem? your the of Do you know your pet’s vaccination history?If your pet is a cat has s/he ever been tested for FeL/FIV?When was the test?What was the result of the test?Has your pet ever suffered from any of the following?Infectious diseaseMajor illnessesAllergiesHas your pet ever been in an accident?If yes, when was the accident?How was your pet treated after the accident?Has your pet had any surgeries except spay/neuter?What is your main complaint today?Since when has this been going on?Has it got worse over time?What was the very first thing you noticed?Has your pet had contact with any other animals?Were they healthy or sick?Are there any new animals in the household?Puppies or kittens?Has another pet or a person in your household gotten sick?Has your pet traveled lately?Has s/he been boarded lately?Is your pet's activity level normal or does it tire easily?Have there been any recent changes in food and/or water consumption?Has there been any vomiting, gagging, diarrhea?Has your pet been treated elsewhere for this current problem?What diagnosis was given?What kind of treatment was given?Is your pet on any medication right now?Anything else you would like us to know about your pet's current problem?Submit