P A T I E N T H I S T O RY

L E X I N G T O N V E T E R I N A RY A S S O C I A T E S
Please complete one form for each pet
Name:

! M

! Dog

! Cat

! Other: ____________

Color:

Breed:

! F

Neutered/Spayed?
! Y
!N
(If yes, at what age?): _________
Birthday:

Age:

Habitat:
! Indoor Only
! Outdoor Only
! Indoor/Outdoor
If indoor/outdoor, please specify: ___ % Indoor ___ % Outdoor
Appetite:

! Very Good

Dry Food(s):

! Erratic

____ cups/day

Treats:
Diet:

! Good

____ pieces/day
! Eats specific/timed meals

Water Consumption:
Activity Level:

! Normal

! Very active

! Picky

! Poor

! Very Poor

Wet Food(s):

____ oz/day

Other Food/Table:

____ oz/day

! Feed free choice
! Increased

! More active

! Decreased

! Normal

____ cups/day

! Less active

! Very inactive

!Y

!N

Do you or plan to board/groom your pet?

!Y

!N

Lameness: Which leg(s)? _______________
Constant
Intermittent
Duration: _____________

!Y

!N

Behavior: Any notable change? Describe ______________________________

!Y

!N

Vomiting: If yes, how often? _____________ What is vomited? ___________

!Y

!N

Diarrhea:
Occasionally
Frequently
Frequency: ________
If diarrhea present: # of bowel movements/day: ____
Type:
! Cow Patty
! Loose
! Watery
! Bloody

!Y

!N

Coughing:

!Y

!N

Sneezing:

!Y

!N

Wheezing:

!Y

!N

Nasal discharge:
Clear
Black
Pus
Watery
Bloody
Duration: ____________________________________________________________

!Y

!N

Itching:
Seasonal
Year round
Location(s) on body: __________________________________________________

!Y

!N

Fleas or Ticks? Describe _____________________________________________

!Y

!N

Flea prevention?
Regularly
Irregularly
Type: _________________________________________

!Y

!N

Heartworm prevention?
Regularly
Irregularly
Type:__________________________________________

!Y

!N

If cat, has pet been tested for FELV? If positive, How long ago?

!Y

!N

If cat, has pet been tested for FIV? If positive, How long ago?

Occasionally
Occasionally
Occasionally

Frequently
Frequently
Frequently

#months used: ______
#months used: ______

Medications currently taking:

Vaccine/Procedure History (check all that pet has received):
DOG: ! Distemper/Parvo
! Bordetella
! Rabies: date ________
! Lyme
! Dental
! Other: _____________________________________________________________________________________
CAT: ! Feline Distemper (FVRCP)
! FELV
! Rabies: date ________
! Lyme
! Dental
! Other: ____________________________________________________________________________________

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