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It collects prior conditions, exposure risks such as ticks and standing water, and symptoms including vomiting, diarrhea, coughing, and sneezing with timing and consistency notes. 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It also captures whether the pet is indoor-only, outdoor-only, or a combination.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form document symptoms and recent illnesses?",{"text":114,"@type":110},"It prompts the owner to mark symptoms such as vomiting, diarrhea, coughing, and sneezing. For any marked item, it requests an explanation including when it first started, duration, and other details like consistency and color.",{"name":116,"@type":107,"acceptedAnswer":117},"What authorization and vaccination/boarding requirements are included?",{"text":118,"@type":110},"The authorization section requests a reachable phone number, approval for treatment up to a specified amount, and whether treatment should be discussed before administration. For boarding patients, it requires current Rabies, DHPP, Bordetella, and CIV (K9 Flu) vaccines and asks for proof or notes that vaccination will be provided if proof is missing.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307730,1790478423,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1374402739827,"https://ap-avatar.wpscdn.com/avatar/14000c97e7351f1a627?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787885694763230660","Canine Patient History Form DATE:   \nName of Pet:  Age:  Male / Female Neutered: Y􀀀 N􀀀  \nMEDICAL HISTORY  \nDoes your pet have any past medical problems? Yes􀀀 No􀀀  \nIf yes please explain :   \n______________________________________________________________________________________  \n.  \nCan we send for records from your previous veterinarian? Yes􀀀 No􀀀  \nName of previous veterinary hospital?   \nAre there any problems that need addressing today? Yes􀀀 No􀀀  \nIf yes please explain ( first noted, duration)   \nIs your pet INDOOR ONLY (no outside contact)  \nOUTDOOR ONLY  \nCOMBINATION INDOOR/OUTDOOR  \nIs your pet exposed to other dogs? (circle all that apply) Yes􀀀 No􀀀 GROOMING FACILITIES, BOARDING FACILITIES, DOG PARK  \nIs your pet exposed to ticks? (circle all that apply) Yes􀀀 No􀀀  \nIN BACK YARD, BRIONES, MARINA, LYME RIDGE, LAFAYETTE RESERVOIR, OTHER  \nIf you marked yes your pet should be vaccinated for Lyme disease. If your dog is due or at risk can we administer the vaccine? Yes􀀀 No􀀀 Wish to discuss w/ Dr 􀀀  \nIs your pet exposed to any standing bodies of water (cow ponds, ponds that raccoons and other wild animals have access to)? Yes􀀀 No􀀀  \nIf you marked yes your pet is at risk for Leptospirosis, a disease transmitted through urine. If your dog is due or at risk can we administer the vaccine? Yes􀀀 No􀀀 Wish to discuss w/ Dr 􀀀  \nHas your pet recently had any of the following: VOMITING (digested food, liquid, blood, color)  \n(Circle all that apply) DIARRHEA (liquid, loose, blood or mucus, color)  \nCOUGHING (how often/long has pet had cough) SNEEZING (how often, nasal discharge, color)  \nIf yes to any of the above please explain (problem first noted, duration, consistency, etc.)  \n\n|  |\n| --- |\n|  |\n\nPlease turn over and complete other side!  \nAppetite: Normal 􀀀 Abnormal 􀀀 (increase or decrease, duration)  Water Intake: Normal 􀀀 Abnormal 􀀀 (increase or decrease, duration)  Urination: Normal 􀀀 Abnormal 􀀀 (frequency, color, straining etc)   Diet: What Brand Dry?   How much do you feed per day?   \nWhat Brand Wet?   How much do you fed per day?  CURRENT MEDICATIONS:  \nHeart worm Prevention Yes􀀀 No􀀀 If yes what Brand and how often?  Flea Prevention Yes􀀀 No􀀀 If yes what brand and how often?   \nOther Medications Yes􀀀 No􀀀 If yes give names, strength, how often and when last given.  \n\n|  |\n| --- |\n|  |\n|  |\n\nIn accordance with the recommendations of the Center for Disease Control we recommend yearly  \nheartworm testing and bi-annual stool testing for intestinal parasites. If your pet is due for either of these  \nlab tests can we perform these services? Yes􀀀 No􀀀 Wish to discuss w/ Dr 􀀀  \nAUTHORIZATION  \nWhat number can we reach you at in the next 24 hrs?   \nIf any non-emergency problems are found by one of our veterinarians which would your like us to perform?  \n(please check one)  \nI authorize up to $  for the treatment of my pet. 􀀀 Or  \nI would like to further discuss treatments to my pet before administered. 􀀀  \nDate:  Signature:   \nIF YOUR PET IS DUE FOR VACCINES AND NO VETERINARY EXAM HAS BEEN GIVEN TO YOUR PET IN THE PAST 30 DAYS (or you have no proof of a current exam), A EXAM FEE WILL BE CHARGED PER PET.  \nBOARDING PATIENTS ONLY  \nHow long will your pet be staying with us? From  to   \nWe require Dogs to be current on Rabies, DHPP, and Bordetella, CIV (K9 Flu) vaccines.  \nDo you have proof of current vaccines? Yes􀀀 No􀀀 If no we will vaccinate your pet here.","cbCail0LTJ2G66J6","https://ap.wps.com/l/cbCail0LTJ2G66J6","pdf",93696,"English","# MEDICAL HISTORY\n## CURRENT MEDICATIONS AND HEALTH MAINTENANCE\n# AUTHORIZATION\n## BOARDING PATIENTS ONLY","[{\"question\":\"What medical history and risk exposure information does the form collect?\",\"answer\":\"It asks whether the pet has had past medical problems and current issues needing attention, plus exposure to other dogs, ticks, grooming/boarding/dog park, and standing bodies of water. It also captures whether the pet is indoor-only, outdoor-only, or a combination.\"},{\"question\":\"How does the form document symptoms and recent illnesses?\",\"answer\":\"It prompts the owner to mark symptoms such as vomiting, diarrhea, coughing, and sneezing. For any marked item, it requests an explanation including when it first started, duration, and other details like consistency and color.\"},{\"question\":\"What authorization and vaccination/boarding requirements are included?\",\"answer\":\"The authorization section requests a reachable phone number, approval for treatment up to a specified amount, and whether treatment should be discussed before administration. For boarding patients, it requires current Rabies, DHPP, Bordetella, and CIV (K9 Flu) vaccines and asks for proof or notes that vaccination will be provided if proof is missing.\"}]","Canine Patient History Form - Request for Pet Medical & Vaccination Information | PDF",1789853886]