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Pet history FORM

The more we know,
the better we can help.

Before your first visit, we’d love to learn about your pet’s background, diet, quirks, and personality. It’s how Dr. Pam builds care plans that actually fit the unique needs of your dog – not just their chart.

Even more helpful is getting information directly from your traditional vet. While this is optional, you may share the link below with them to complete:

Patient History

Give us all the info we need to paint a complete picture of your pet's health.

Email *

First Name *

Last Name *

Pet's Name *

Overview

What is your main health concern? *

What are your secondary concerns, in order of importance? *

What was the first issue you noticed, and when? *

Current Diet & Medications

Diet

Dietary Supplements & Dosages

Current Heartworm Prevention *

Yes

No

If yes, Brand/Type of Heartworm Medication

Current Flea Prevention *

Yes

No

If yes, current flea preventative used

Current Pharmaceuticals & Dosages

Acquisition

Age when Acquired *

Was pet spayed/neutered prior to acquisition? *

Yes

No

Vaccination History

Was pet vaccinated prior to acquisition? *

Yes

No

What were the most recent vaccines, and when? *

Any known reaction to vaccines? *

Yes

No

If yes, what vaccine caused the reaction and what were the symptoms?

List any vaccine blood antibody titers and dates *

General Health Overview

Emotional/Mental (check all that apply)

Excitable

Grounded

Structured

Fearful

Bossy

Startles easily

Irritable

Anxious

Needy

Flighty

Hides frequently

Aggressive toward other pets

Aggressive toward humans

Growling/snapping

Loves other pets

Loves people

Any other emotional/mental notes

Cognitive (check all that apply)

Sharp

Mostly sharp with some dull moments

Dull

Confused

Staring into space

Gets stuck in corners

Variable symptoms

Consistent symptoms

Senses

Vision *

Normal

Diminished

Blind

Eyes (check all that apply) *

No issues

Redness

Discharge

Cloudy eyes

Corneal ulcers

Pigment

Trauma

Ulcers

Hearing *

Normal

Slight reduction

Selective hearing

Obvious decrease

Deafness

Ears (check all that apply) *

Normal

Infection

Flushed ear cartilage

Wax in ears

Smelly ears

Shaking ears

Scratching ears

PSOM (primary secretory otitis media)

Ear ablation

Any additional ear notes

Smell *

Apparently normal

Sensitive to odors

Diminished

Any other smell notes

Nose (check all that apply) *

Normal

Clear discharge

Cloudy discharge

Green or yellow discharge

Bloody discharge

Discharge, one nostril

Discharge, both nostrils

Congestion

Any other nose notes

Energy levels (check all that apply) *

Bright and alert

Robust

Strong endurance

Sickly

Tires easily

Dull and depressed

Better in the morning

Better in the afternoon

Any additional energy level notes

Respiratory (check all that apply) *

No issues

Coughing

Sneezing

Reverse sneezing

Wheezing

Heavy breathing

Excessive panting

Panting at night

Fluid in lungs

Additional respiratory notes

Heart (check all that apply) *

Apparently normal

Exercise intolerance

Murmur

Coughing

Arrhythmia

Atrial or ventricular fibrillation

Genetic defect

On medication

Seeing a cardiologist

Any other heart notes

GI (Gastrointestinal) Health

Appetite (check all that apply) *

Finicky

Decreased

Normal

Excessive

Better in the morning

Better at night

Additional appetite notes

Thirst (check all that apply) *

Normal

Small, frequent sips

Large amounts infrequently

Increased overall

Decreased overall

Not much of a drinker

Any other thirst notes

Breath *

Good

Varies from good to bad

Bad all the time

Dental disease *

Healthy teeth and gums

Mild

Moderate

Severe

Build tartar easily

None

Stool (check all that apply) *

Formed and moist

Formed and dry

Soft formed

Cow patty

Watery

increased frequency

Straining

Any other stool notes

Daily frequency *

1 - 2

3 - 4

5+

Blood in stool *

Yes

No

Mucus in stool *

Yes

No

Any other mucus notes

Stool odor *

Normal

Abnormal

GI Events

Gastrointestinal events (check all that apply) *

Tendency toward abnormal stool

Tendency to vomit

Stress-induced issues

Dietary indiscretion

Pancreatitis

None

Other gastrointestinal event notes

GI Hospitalization

Has your pet been diagnosed with a GI issue? *

GI diagnostics (check all that apply) *

None

Fecal

Lab

GI panel

Imaging

Barium study

Other GI diagnostic notes

Has patient been hospitalized for a GI issue? *

Yes

No

GI Indicators

Belching *

Yes

No

Gas (check all that apply) *

None

Silent with odor

Loud with no odor

Frequent

Occasional

Any other gas notes

Gas is made better or worse by...

Gurgling (check all that apply) *

None

Rumbling

High pitched (fireworks)

Squealing

Any other gurgling notes

Is there a pattern of when gurgling occurs?

Bad breath *

Yes

No

Forms tartar easily *

Yes

No

Smacking *

None

After eating

Randomly throughout the day

Hard swallowing *

Yes

No

Sleep

Sleep Patterns (check all that apply) *

Sleeps throughout the night

Restless

Changes position

Walks around the house in the middle of the night

Any additional sleep notes

Dreaming (check all that apply) *

None

Vocalizing

Movement/"chasing squirrels"

Any other dream notes

Musculoskeletal

Musculoskeletal (check all that apply) *

No issues

Limping

Weakness

Stiffness

Muscle soreness

Groans with movement

Arthritis

Joint pain

Hip dysplasia

Luxating kneecaps

Neck issues

Disc issues

Any other musculoskeletal notes

Movement (check all that apply) *

Normal

Bunny hops

Limping

Difficulty rising

Difficulty sitting

Improves with movement

Worsens with movement

Normal movement

Any other movement notes

Diagnostics (check all that apply) *

Xray

MRI

CT scan

Ultrasound

Specialized bloodwork

None

Any additional diagnostics

Neurological

Neurology (check all that apply)

Seizure/tics/tremors

Neurologic imaging (MRI, CT)

Neuro meds

Any other neurological notes

Genitourinary System

Urinary health (check all that apply) *

Normal

Strong odor

Light color

Dark color

Increased frequency

Straining

History of UTI

Leaking

Odd urination pattern

Any other urinary health notes

Reproductive status *

Intact

Spayed/Neutered

Vasectomy/OSS (ovary sparing surgery)

What was pet's age at time of operation?

How was the recovery?

Good

Difficulty waking

Vomiting

Any other surgery recovery notes

How was the healing process?

Good

Suture reaction

Swelling

Any additional healing notes

Skin & Hair/Coat

Symptoms (check all that apply) *

None

Scratching

Biting

Bleeding

Hot spots

Oily coat

Dull coat

Body odor

Flakey skin

Crusts and scabbing

Hair loss

Pimples/pustules

Increased hair loss or shedding

Seasonal occurrence

Better with bathing

Worse with bathing

Tendency to get fleas

Started within two months of vaccination

Any other skin or coat notes

External Indicators (check all that apply) *

None

Decreased nose pigment

Decreased pigment of eye liners

Dull coat

Decreased color of fur at skin level

Decreased pigment of paw pads

Rough paw pads

Decreased coat color contrast (if multiple colors)

Any other external indicator notes

Dermatology consults

Yes

No

Meds used (check all that apply) *

None

Steriods

Antihistamines

Apoquel

Cytopoint

Topical treatment

Any other meds used

Documents

Medical records from your vet *

Lab results

X-Rays

X-Ray Link

Should you not have a file to upload

214.991.2240

454 Houston Street Coppell, TX‍

The information provided at this site has not been evaluated by the US Food and Drug Administration and is for educational purposes only.
It is not intended as a diagnosis, treatment, or prescription for any diseases.

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