Owner's Name *

Email *

(for pet reminders and the occasional newsletter)

Pet's Name

Breed

Color

Date of Birth or Age

Sex

Male
Female
Neutered Male
Spayed Female

If intact, will this pet be used for breeding purposes?

Yes
No

If mature female, when was her last heat cycle?

Has your pet had bad experiences at a veterinary hospital before

Yes
No

Please explain:

Are special precautions or handling techniques required?

Yes
No

Please explain:

If larger pet, will it be best examined on a table or floor?

Table
Floor

How long have you owned this pet?

If new pet, where did you get the pet?

Individual
Breeder
Shelter
Pet Store

Is your pet housed

Indoor only
Indoor/Outdoors
Outdoors only

If goes outdoors

What brand of pet food do you feed?

Meals or free choice?

Meals
Free choice

General Information

Are there other pets in your household?

Yes
No

If yes, species and numbers?

Does your pet go to off leash dog parks?

Yes
No

Does your pet go swimming?

Yes
No

Is your pet groomed professionally?

Yes
No

Is your pet boarded?

Yes
No

If so, how often.

Vaccination Information (if you know)

Dog

Date of last Rabies vaccination

Date of last DA2PPC (Distemper) vaccination

Date of last Bordetella vaccination

Date of last Lymes vaccination

Cat

Date of last Rabies vaccination

Date of last FVRCPP (Distemper) vaccination

Date of last FeLV (leukemia) vaccination

Date of last FIV vaccination

Parasites

Does your pet eat insects, rodents, birds or rabbits?

Yes
No

Are you seeing fleas, ticks, worms or other parasites?

Yes
No

Do you keep your pet on monthly flea prevention?

Yes
No

Do you keep your pet on monthly heartworm prevention?

Yes
No

Do you need heartworm or flea prevention today?

Yes
No

When was your pet last tested for heartworms?

When is the last time your pet had a fecal exam?

General Health Questionnaire

1. Has your pet ever had any vaccination reactions?

Yes
No

2. Does your pet have adverse reactions to any medications? Anesthesia?

Yes
No

3. Is your pet currently on any medications?

Yes
No

4. Has your pet been diagnosed with any illness?

Yes
No

5. Eyes- Does your pet have any eye problems, discharge, redness?

Yes
No

6. Mouth- Does your pet have bad breath or problems eating?

Yes
No

7. Nose- Does your pet sneeze, snort or has nasal discharge?

Yes
No

8. Ears- Does your pet shake its head, scratch its ears, rub head on floor, have ear odors or discharge?

Yes
No

9. Respiratory- Does your pet cough; have increased respiratory effort or rate?

Yes
No

10. Heart- Does your pet need to rest more frequently after exercise?

Yes
No

11. 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?

Yes
No

12. Neurological- Has your pet ever had seizures?

Yes
No

13. 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.

Yes
No

14. 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?

Yes
No

15. General- Has the amount of water consumed by your pet changed?

Yes
No

16. Has your pet’s appetite changed?

Yes
No

17. Does your pet pant more frequently?

Yes
No

18. Does your pet vomit? (other than occasional hairball if cat)

Yes
No

19. Are your pet’s feces abnormal? Diarrhea? Straining? Loss of housetraining?

Yes
No

20. Is your pet less active than normal?

Yes
No

21. Does your pet scoot on its bottom?

Yes
No

22. Has your pet’s weight decreased?

Yes
No

23. 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?

Yes
No

24. Has your pet ever had bloodwork performed?

Yes
No

If 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. *

Yes
No

New Patient Form