Health History/Appointment Concerns Form

Save time during your next appointment! Complete your required health history/appointment concerns form online from any device before your visit.

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Health History/Appointment Concerns Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Your Name *

First

Last

Pet's Name *

First

Phone *

What type of visit is your pet here for? *

Illness Visit for your Dog
Illness Visit for your Cat
Dog Wellness/Annual Visit
Cat Wellness/Annual Visit
Puppy/New Dog First Visit
Kitten/New Cat First Visit
Kitten/Puppy Progress Check
Technician Visit (Blooddraw, Nail Trim, Vaccine booster, etc.)

Eating

Normal
Increased
Decreased

Drinking

Normal
Increased
Decreased

Activity

Normal
Increased
Decreased

Diet (Brand name; Grain-Free or Not Grain-Free) *

Portion Size *

Feeding Frequency *

Urinating

Normal
Increased
Decreased

Urinary Discomfort - Check all that apply

None
Straining
Blood Preent
Other

(A urine sample is recommended if any urinary discomfort is present.)

Defecating

Normal
Increased
Decreased

Diarrhea - Check all that apply

None
Soft
Watery
Large Volume Produced
Small Volume Produced
Straining
Blood
Mucus

(A fecal sample is recommended yearly to check for parasites but especially recommended if diarrhea is seen.)

Vomiting Frequency

Multiple times per day
Daily
Weekly
Monthly
Rarely
Never

Vomiting - Check all that apply

None
Food
Bile
Blood

(A fecal sample is recommended yearly to check for parasites but especially recommended if diarrhea is seen.)

Last time vomited

Coughing

Multiple times per day
Daily
Monthly
Rarely
Never

Last time coughed

Productive Coughing - Check all that apply

None
Clear/Salive
Foam
Bile
Food
Blood

Sneezing

Multiple times per day
Daily
Monthly
Rarely
Never

Last Time Sneezed

Productive Sneezing - Check all that apply

None
Clear
Green/Yellow
Blood

Eyes - Check all that apply

Doing well/no concerns
Redness
Squinting
Swelling
Rubbing
One Eye
Both Eyes
Noticed Today
Few Days
Few Weeks
Chronic
Other

Able to clean eyes or apply topical medications if needed?

Ears - Check all that apply

Doing well/no concerns
Redness
Debris
Itchy
Painful
One Ear
Both Ears
Noticed Today
Few Days
Few Weeks
Chronic
Other

Able to clean ears or apply topical medications if needed?

Ear cleaning frequency?

Daily
Monthly
Weekly
Never

Lameness - Check all that apply

None
Front leg
Back leg
Multiple legs
Swelling
Wound
Noticed today
Few days
Few weeks
Chronic
Other

Skin/Haircoat Issues - Check all that apply

None
Itchy
Redness
Crusts
Odor
Wound
Masses
Other

Location of Skin Concerns

Duration of Skin Concerns

What Flea/Tick and Heartworm Prevention is being used? Choose all that apply. *

Simparica Trio: combination
Flea/Tick/Heartworm/intestinal parasites (monthly)
Seresto® Collar Flea & Tick: (replace every 6 monhts)
NexGard®: Flea&Tick (monthly)
FRONTLINE® Plus for Dogs: Flea&Tick (monthly)
Heartgard® Plus Heartworm/intestinal parasites (monthly)
Tri-Heart® Plus: Heartworm/intestinal parasites (monthly)
Revolution: Heartworm/Flea/intestinal parasites (monthly)
None
Other

Recommended all year round. For more information on parasites: Companion Animal Parasite Council | Home (capcvet.org)

Current Medications & Dosing (including supplements)

Seizures?

Seizure Status (If applicable): frequency? medication-controlled?

Behavioral Concerns

Previous Vaccine Reaction - Check all that apply *

None
Pain
Inappetance
Swelling
Other

Medical Conditions

Do you need any refills of any medications (preventative or therapeutics)? *

Are there any other concerns you would like to discuss with the doctor? *

Message

We’re excited to meet you

We proudly serve pets in Mendon, MA, and surrounding areas. We look forward to seeing you and your pet. We have a state-of-the-art veterinary facility that is clean, comfortable, and efficient. You can call 508-478-7387 to schedule an appointment or click on the button below.

Appointment

Have a Question?

Complete our online form, and a member of our team will be in touch with you shortly.

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Location

128 Uxbridge Road
Mendon, MA 01756

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Contact Information

Phone: 508-478-7387
Fax: 508-478-8523
Email: info@mendonanimalclinic.com

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Hours

Monday-Friday: 8 am-6 pm
Saturday: 8:30 am – 1 pm
Sunday: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

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