Patient History Form Curb Side SAH R4

Lauryn Ashlee Oliver-Frey

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Patient History Form:

Date: _______________________________
© Ashlee Oliver-Frey, DVM 2020

Answering the following questions to the best of your ability will ensure the safety of our staff and conservation of our limited personal protective equipment whilee ttaakkiinnggccaarreeoof fyyoouur rfuprebtatobydatoyd. ay.
1. Have you or your pet traveled outside of Alaska in the past 2 weeks? [ ] yes or [ ] no. 2. Have you or someone in your home experienced respiratory symptoms (cough, sneeze, fever) in the past 2 weeks? [ ] yes or [ ] no. 3. Have you been asked to quarantine yourself by a health official or physician in the past 2 weeks? [ ] yes or [ ] no.

This form allows our doctors to obtain a detailed history to aid us in the examination of your pet. Please fill out this form as completely as possible. You may write on the back of this form if more space is needed.

Reason for visit today_____________________________________________________________________________________ This issue began on __________________ and is [ ] improving, [ ] worsening/progressing, or [ ] not changing

Has your pet had any [ ] coughing, [ ] sneezing, [ ] vomiting, [ ] diarrhea, [ ] scratching (ears/face/body), [ ] new/changing lumps or bumps, [ ] behavior changes, or [ ] mobility issues? If yes, please describe (if applicable) amount, frequency, color, consistency, and duration of ailment. [ ] Blood present. __________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Appetite: [ ] increased, [ ] normal, [ ] decreased; for how long?________ days/weeks/months. Thirst : [ ] increased, [ ] normal, [ ] decreased; for how long? ________ days/weeks/months. Activity level: [ ] increased, [ ] normal, [ ] lethargic; for how long? _______ days/weeks/months. Urination: [ ] abnormal or [ ] normal. If abnormal, Please note color, amount, frequency, and duration of abnormality. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________
Diet: (including treats/people food) ___________________________________________________________________________ [ ] This diet has changed in the past 6 months. [ ] Grain free. [ ] Garbage/bones. [ ] Missing toys/pieces. [ ] Possible Toxin.

Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:__________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Is your pet current on vaccinations? [ ] yes, [ ] no, [ ] unsure. Does your pet have a microchip? [ ] yes, [ ] no, [ ] unsure. If you answered no/unsure to the above questions, would you like to discuss vaccination/microchip with your pet's Doctor? [ ] yes or [ ] not today.
Anything else you would like us to know about your pet? _________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Please remain in your vehicle. Once you arrive, please call our front desk at
990077--324640--77985113.. Thank you for your understanding and patience!

42479 Sterling Hwy Soldotna, AK 99669

Best Contact Number:

_________________________________ Pet Name
_________________________________ Owner First Name
_________________________________ Owner Last Name