Patient History Form – Veterinarians in Winnipeg | Dakota Veterinary Hospital

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Patient History Form

Please fill out as accurately as possible.

Name
First Last
Phone
Email
Pet's Name
Age
Breed
Sex
- Male
- Female
Eating/Drinking:
- Normal
- Abnormal
If abnormal, please explain:
Diet:
Brand
Type
Diet Start Date:
Vomiting/Diarrhea:
- Present
- Absent
If present please explain
Urination/Bowel Movements
- Normal
- Abnormal
If abnormal, please explain:
Coughing/Sneezing/Wheezing
- Present
- Absent
If so, please explain:
Itchy/Scratching/Head Shaking:
- Present
- Absent
If so, please explain:
Excessive Grooming/Licking
- Present
- Absent
If so, please explain:
Scooting:
- Present
- Absent
If so, please explain:
Lumps/Bumps:
- Present
- Absent
If present, please explain:
Energy Level:
- Normal
- Abnormal
If abnormal, please explain:
Mobility:
- No Change
- Decreased/Changed
If changed, please explain:
On Heartworm Medication/Tick Prevention Last Season?
- Yes
- No
If yes, which medications where used?
Please list all current medications:
Has your pet travelled out of province in the past 12 months?
- Yes
- No
If yes, please specify where:
Any other pets in the home?
- Yes
- No
If yes, what type and quantity?
Any recent contact with other animals?
Do you have pet insurance?
- Yes
- No
Are you interested in pet insurance?
- Yes
- No
- Feline- Strictly Indoor
- Goes outdoors
- Outdoor only in enclosure
- Outdoor on leash/supervised
Other Concerns/Remarks:

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