Patient Health Questionnaire

New Patient?*
- Yes (Please fill out New Client Form)
- No (Please fill information below)
Please let us know if you are a new client/new patient to our hospital.
Last Name:*
Last name that your pet would be under in the chart.
Pet's Name:*
Pet name we have in chart
Any coughing or sneezing? How often?
Any vomiting or diarrhea? How often? What did it look like? Anything unusual in it?
Any change in appetite or thirst?
Any observed lumps or bumps? Have any of them grown? How long have you noticed them?
Any observed soreness or stiffness after resting or exercise? How long has it been going on for?
Any changes urination or bowel movements? Any inappropriate elimination?
Is your pet acting lethargic (not acting there self)? If so, how long has it been going on for?
Any bad breath? Rate on a scale of 1-10, 10 being absolutely horrible.
Any observed change in weight? How long have you noticed the change?
What brand of food do you feed? How much and often do you feed? Any table scraps?
Is your pet current on monthly heartworm preventative and which brand?
Is your pet current on monthly flea control and which brand?
Is your pet on any medication? How many milligrams? How often are your giving the medication?
Is your pet current on vaccines and heartworm test? If done elsewhere, where were they done?
Any other concerns?
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