Patient History Form

Welcome to 716Vet! We are excited that you have chosen us to be a part of your pet’s health care. We are dedicated to providing convenient, comprehensive, and cost effective care for your furry family member! This form is intended to collect the information necessary for us to initiate, populate, and maintain appropriate client and medical records and most importantly to obtain pertinent medical and and historical information about your pet. This form may take some time to answer and we apologize for all the work that goes into getting this done. Just know that a lot of this information is important and that we are only collecting it to make sure we have all the information we need to help make your pet feel better. Please get the INTAKE and CONSENT form filled out first, then work to tackle this one. We can get started working with your pet while you’re working on this form.

Name(s)?(Required)

First Last

Email(Required)

We know this is a little redundant, you just filled out names on the last form but this helps us match the history form to the intake form! Please enter your full name AND your pet’s name.

Why is your pet here today?(Required)

Tell us a little bit about why your pet is here today. If you filled this out completely on the first form just say “see intake form”. Sometimes, parents remember things as they work through these forms, this gives you the chance to add additional information.

Does your pet have any prior medical problems?(Required)

This may include allergies, vaccine reactions, surgeries, trips to the emergency room, or other ongoing issues that have required veterinary care.

Have you noticed your pet coughing or sneezing recently?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Has your pet vomited in the last week?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Has your pet had diarrhea in the last week?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Has your pet been drinking and eating normally at home?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

What food does your pet normally eat?

It’s not a big deal if you can’t remember the name/brand of the food, just skip this question.

How much food does your pet eat daily?

Also not a big deal if you don’t know this. These questions are also designed to get you thinking about whether your pet has been eating normally at home.

Does your pet ever chew on or destroy toys on non-food items at home?(Required)

Yes

Other

Think about socks and underwear, trash, toys, and other things that pets often chew or eat at home. Is it possible that your pet may have gotten into a similar item?

Has your pet been going to the bathroom normally at home?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Do you think your pet has been drinking a normal amount of water recently?(Required)

Yes

Other

Sometimes when pets are sick, they’ll drink extra water or they’ll stop drinking. If you would like to make a note, just click ‘other’ and type it there.

Is your pet up-to-date on their vaccines?(Required)

Does your pet get their vaccines regularly? If so, what vaccines have been given and when were they last administered?

Does your pet take any medications?(Required)

This might be THE most important question on this form. Does your pet take ANY medications at home? This may include medications prescribed by a veterinarian, over the counter medications, supplements, or vitamins/minerals you give. This includes aspirin, ibuprofen or Benadryl.

Does your pet have any known allergies?(Required)

You may include suspected allergies as well, but please specify if they are suspected or known.

Does your pet regularly receive flea/tick prevention?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Have you ever found a tick on your pet?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Has your pet ever traveled outside of New York?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there.

Do you think there is a chance your pet may have gotten into a toxin at home?(Required)

Yes

Other

If you would like to make a note, just click ‘other’ and type it there. Toxins often include rodenticides (rat bait), fertilizers, pesticides, and household cleaners. This also includes mold, like moldy food or trash.

Do you have any other pets?(Required)

If there are other pets at home, please list them here (name and type of animal). If they are unhealthy, please let us know what you are seeing at home.

Does your pet ever go to the dog park or share green-space with other pets or animals like in an apartment complex or neighborhood playground?(Required)

Yes

Other

If you would like to make a note, just click “other” and type it there.

Where does your pet spend most of their day?(Required)

Inside

Outside

Equal mix of both

Other

Consent

I AGREE TO THE TERMS AND CONDITIONS

Consent and Verification
I have reviewed the above information and acknowledge that it is complete and accurate. I understand that a failure to report complete and accurate information may influence the decisions of treating doctors and nurses resulting in ineffective or potentially life threatening therapies. I understand that I can update, change, modify, or alter this information AT ANY TIME by making an employee of 716Vet aware of the new information.

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(716) 949-0161

Hours of Operation

Patient History Form

Text Now (716) 949-0161