Patient History Form – Veterinarians Skokie

Name*

First Last

Pet Name*

Email*

Cell Phone Number*

Reason for the Visit*

Appointment Date*

Doctor

Please let us know which doctor your pet will be seeing. If unsure please leave blank.

Health Screen*

Seizure Activity

Seizure Activity

Please provide more information in regards to the seizure activity... (Last seizure, frequency, duration, etc)

Adverse reactions to medications or vaccinations

Adverse Reactions

Please provide information in regards to the history of adverse reactions...

Additional information or concerns

Please provide more information for any health issues checked off above: such as duration, frequency, and severity of the concern.

Lifestyle*

Please tell us about your pet's lifestyle.

Are there other pets in the household?*

Diet: (Brand, type, amount, and frequency)*

Is your pet currently taking medications?*

List current medications

Do you need a refill of medication?

Medication(s) to refill:

Parasite Preventatives*

Parasite preventatives are recommended year-round. Please check off the preventative your pet is taking.

Other:

If you checked off other under the parasite preventative section please let us know what preventative medication your pet is receiving.

Does your pet need a refill of parasite preventatives?

Additional services needed today

Other:

Additional Comments: