Patient Intake Form

Owners First and Last Name (must match name on account):

Pets Name:

Date of Scheduled Exam:

Describe your pet's appetite:

If you marked increased or decreased, by what percentage?

Describe your pet's water intake:

If you marked increased or decreased, by what percentage?

Does your pet get any table scraps?

If yes, what kind?

What kind of treats does your pet get?

What is your pet's current diet, amount, and frequency? (ex: Science Diet adult 1-6 dry food, 1/2 cup twice a day)

At home, my pet is:

My yard is accessible to stray cats, rodents, wild pigs, mongoose?

How often and how long does your pet go for walks?

Do you take your pet anywhere other than walks around the neighborhood? (ex: hikes, beach, dog parks) If yes, where do they go?

Are there any environmental factors that your pet may be exposed to on a regular basis? (ex: dust, smoke, inhalants/aerosols, fertilizers/baits/poisons)

Have you noticed any of the following symptoms?

coughing

sneezing

diarrhea

vomiting

If you checked yes to any symptom above, to what frequency have they been occurring? When did it start? Has there been any changes since onset?

Have you noticed any change to your pet's normal pattern of urination?

Have you noticed any change to your pet's normal pattern or defecation?

Is your pet current on heartworm prevention?

If yes, what brand?

Is your pet current on flea/tick prevention?

If yes, what brand?

Please list all current prescriptions with their respective dosages.

Please list all over the counter medications or supplements that you give with their dosages.

Does you pet have any known allergies? If yes, please list them here.

Does your pet have any known reactions to any medication or vaccination? If yes, please list them here.

Since your last visit at MTCPC, has your pet been seen at another veterinary clinic or emergency hospital? If yes, please let us know when and where they were seen?

Are there any specific concerns that you would like doctor to address at your appointment?

Patient History Form

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