Patient Medical History – Rathdrum Animal Clinic

Owner Name*
Phone*
Email*
Patient Name*
Appointment Date*
Reason for Visit*
Does your pet have any previous problems or chronic conditions?*
If yes, describe.
How is your pet's appetite?*
How is your pet's water intake?*
How is your pet's urination?*
Is your pet having diarrhea?*
If yes, for how long?
Has your pet been vomiting?*
If yes, how often and for how long?
How is your pet's activity level?*
Does your pet have any mobility issues?*
Walking, Standing, Running, etc.
Have you noticed any changes in your pet's behavior?*
If yes, describe.
Has your pet been sneezing, coughing, or had any other respiratory issues?*
If yes, describe.
Does your pet have any issues with their Eyes, Mouth, Ears, Skin?*
If yes, describe.
Is your pet currently taking any medications or supplements?*
If yes, which ones?
What, How Much, and How Often do you feed your pet?*
Type of food, 1 cup, 2 cups, Once daily, Twice daily, Free feed, Etc.
Do you travel with you pet or have they ever been away from the North Idaho area?*
If yes, where?
Do you take your pet to a boarding or grooming facility, dog park, pet store, etc.?*
How much time does your pet spend indoors vs. outdoors?*
Is your pet currently on Flea, Tick, and/or Heartworm Prevention?*
Is yes, what type?
Are there any topics that you would like to discuss at your visit?*
Has your pet been exposed to anyone who is ill or who has a confirmed case of COVID-19? If yes, when were they exposed?*