New Patient Medical History Questionnaire in Las Vegas, NV - Las Vegas Veterinary Specialty Center

Client Name

Phone

Pet's Name

What is your primary concern today?

Was food withheld for today’s visit?

Yes
No

What time was your pet last fed?

What food(s) does your pet eat?

What treats do they receive?

Has your pet’s activity level changed recently?

Yes
No

If yes

Has your pet’s appetite changed recently?

Yes
No

If yes

Has your pet’s weight changed recently?

Yes
No

If yes

Has your pet’s water consumption changed recently?

Yes
No

If yes

Has your pet been vomiting recently?

Yes
No

Frequency

Please enter the number of times you pet has been vomiting and per day or per week.

Have your pet’s defecations changed recently?

Yes
No

If yes

Have your pet’s urination habits changed recently?

Yes
No

If yes

Has your pet’s breathing changed recently?

Yes
No

If yes

Select all that apply

Is your pet current on vaccinations?

Yes
No

How long have you owned your pet?

Where was your pet obtained?

Has your pet had any seizures or fainting episodes?

Yes
No

Are there any lumps or bumps on your pet?

Yes
No

Is your pet in pain?

Yes
No

If yes…Where?

For how long?

Has there been a recent change in your pet’s behavior?

Yes
No

If yes…Describe

Has your pet been treated for any previous medical conditions or surgery?

Yes
No

If yes…Describe

Has your pet been hospitalized recently?

Yes
No

If yes, when and where

Have they been seen anywhere else for this issue?

Yes
No
N/A

If yes, where

Has your pet traveled out of Nevada within the last 5 years?

Yes
No

Where is your pet kept primarily?

Indoor
Outdoor

Is your pet on any current medications?

Yes
No

If yes, please list

Do you need any medication refills?

Yes
No

If yes, which meds

Has your pet had any reaction to a medication before?

Yes
No

If yes, which meds

Cats only: Has your cat been diagnosed with FeLV?

Yes
No
N/A

Cats only: Has your cat been diagnosed with FIV?

Yes
No
N/A

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