New Patient Form Please enable JavaScript in your browser to complete this form.Owner's Name *Email *(for pet reminders and the occasional newsletter)Pet's NameBreedColorDate of Birth or AgeSexMaleFemaleNeutered MaleSpayed FemaleIf intact, will this pet be used for breeding purposes?YesNoIf mature female, when was her last heat cycle?Has your pet had bad experiences at a veterinary hospital beforeYesNoPlease explain:Are special precautions or handling techniques required?YesNoPlease explain: If larger pet, will it be best examined on a table or floor?TableFloorHow long have you owned this pet?If new pet, where did you get the pet? IndividualBreederShelterPet StoreIs your pet housed Indoor onlyIndoor/OutdoorsOutdoors onlyIf goes outdoors Free roamingFenced yardOutdoor kennelChainedLeash walked onlyWhat brand of pet food do you feed?Meals or free choice?MealsFree choiceGeneral InformationAre there other pets in your household?YesNoIf yes, species and numbers?Does your pet go to off leash dog parks?YesNoDoes your pet go swimming?YesNoIs your pet groomed professionally? YesNoIs your pet boarded?YesNoIf so, how often.Vaccination Information (if you know)DogDate of last Rabies vaccinationDate of last DA2PPC (Distemper) vaccinationDate of last Bordetella vaccinationDate of last Lymes vaccinationCatDate of last Rabies vaccinationDate of last FVRCPP (Distemper) vaccinationDate of last FeLV (leukemia) vaccinationDate of last FIV vaccinationParasitesDoes your pet eat insects, rodents, birds or rabbits?YesNoAre you seeing fleas, ticks, worms or other parasites?YesNoDo you keep your pet on monthly flea prevention?YesNoDo you keep your pet on monthly heartworm prevention?YesNoDo you need heartworm or flea prevention today?YesNoWhen was your pet last tested for heartworms? When is the last time your pet had a fecal exam?General Health Questionnaire1. Has your pet ever had any vaccination reactions?YesNo2. Does your pet have adverse reactions to any medications? Anesthesia?YesNo3. Is your pet currently on any medications?YesNo4. Has your pet been diagnosed with any illness?YesNo5. Eyes- Does your pet have any eye problems, discharge, redness?YesNo6. Mouth- Does your pet have bad breath or problems eating?YesNo7. Nose- Does your pet sneeze, snort or has nasal discharge?YesNo8. Ears- Does your pet shake its head, scratch its ears, rub head on floor, have ear odors or discharge?YesNo9. Respiratory- Does your pet cough; have increased respiratory effort or rate?YesNo10. Heart- Does your pet need to rest more frequently after exercise? YesNo11. Musculoskeletal- Does your pet have difficulties rising from lying or sitting? Going up/down stairs? Jumping onto furniture or into a vehicle? Does your pet limp or carry a leg?YesNo12. Neurological- Has your pet ever had seizures?YesNo13. Skin- Does your pet have any areas of hair loss, oily, flaky or malodorous hair coat, lick its skin or paws excessively, scratch or have any skin or subcutaneous bumps.YesNo14. Urinary- Does your pet have urinary accidents in your house, leave a wet spot left after it has been sleeping, urinate more frequently or strains to urinate?YesNo15. General- Has the amount of water consumed by your pet changed?YesNo16. Has your pet’s appetite changed?YesNo17. Does your pet pant more frequently?YesNo18. Does your pet vomit? (other than occasional hairball if cat)YesNo19. Are your pet’s feces abnormal? Diarrhea? Straining? Loss of housetraining?YesNo20. Is your pet less active than normal?YesNo21. Does your pet scoot on its bottom?YesNo22. Has your pet’s weight decreased?YesNo23. If geriatric, does your pet sometimes act disoriented, confused, wanders aimlessly, has its sleeping patterns changed, does it have decreased interactions with family members or other pets, does it not recognize familiar people or respond to verbal clues?YesNo24. Has your pet ever had bloodwork performed?YesNoIf you answer yes to any questions, please list the number of the question followed by a description including how long it has been occurring, its frequency, and if getting better or worse? Was there any known event that could have caused the symptoms to occur? Has it been treated in the past?Do you give Oakbrook Animal Hospital permission to take photographs of your pet, and to publish those photographs for any lawful purpose, including, but not limited to, their website, social media accounts, and promotional materials, either digital or in print, in perpetuity. *YesNoWebsiteSubmit