Please take a moment to complete our history intake form—this helps us ensure a smooth and efficient visit for your upcoming appointment. As an AAHA-accredited animal hospital, providing top-notch, high-quality care is our number one priority.

Medical History Questionnaire

Step 1 of 21

First name of person completing this questionnaire:(Required)

Last name of person completing this questionnaire:(Required)

Pet's Name:(Required)

Consent(Required)

I certify that I am the owner or authorized agent for the owner of the pet listed above.

Owner's First Name:(Required)

Owner's Last Name:(Required)

Owner's Phone Number:(Required)

Owner's Email:(Required)

Consent(Required)

I acknowledge that Johnston Animal Hospital accepts payment by cash, debit, Visa, Mastercard, and Discover only.

Consent(Required)

I understand I will be given a health care plan to review at the time of my pet’s appointment at Johnston Animal Hospital. I acknowledge that I am responsible for payment in full for the procedures and treatments at patient discharge.

What is the reason for your pet's upcoming visit?(Required)

Wellness or sick? (If sick, please explain your concern)

Genetic Testing – Some dogs and cats have a genetic mutation that can make them experience adverse reactions or even death if given certain drugs. Dog breeds that are commonly affected include, but are not limited to, herding dogs, collies, Australian shepherds, Shelties, whippets, German shepherds, and some mixed breed dogs. Approximately 4 million cats in the US have this genetic mutation. An easy blood test can give the doctors the information they need to protect your pet. Are you interested in learning more about having your pet tested for this genetic mutation so your pet can be better protected from harm or death due to adverse reactions to common medications?(Required)

Yes

My pet has had this test in the past.

Select your pet's species(Required)

Dog

Cat

Do you give your pet heartworm prevention year round?(Required)

January-December

Yes

How often do you give heartworm prevention to your pet?(Required)

Once every 30 days

Once every 6 months

Yearly on the same date

Never

Which brand of heartworm prevention do you give your pet?(Required)

When did you give your pet their last dose of heartworm prevention?(Required)

Do you struggle to give your pet heartworm prevention regularly? Did you know there’s an injectable heartworm prevention for dogs? Would you like to learn more?(Required)

Yes, I would like to learn more about injectable heartworm prevention for my pet

No, I would not like to learn more about injectable heartworm prevention for my pet

Does your pet have any history of vaccine reactions?(Required)

Yes

Uncertain

Please specify the type of reaction your pet experienced and the vaccine associated with it.(Required)

Has your pet received vaccines anywhere other than Johnston Animal Hospital?(Required)

No, my pet has only received vaccines at Johnston Animal Hospital

Yes, my pet has received vaccines at another facility

Do you have copies of your pet’s medical history from the previous facility?(Required)

Yes

Please upload your pet’s medical history from the previous facility below.(Required)

Max. file size: 256 MB.

Do you give Johnston Animal Hospital permission to contact the facility for your pet's medical history.(Required)

If you select no, then your pet will need to restart all vaccine series unless medical history is provided from another veterinary facility.

Yes

Facility Name(Required)

We will contact the facility for your pet’s medical history.

Facility's Phone Number(Required)

Facility's Address(Required)

Street Address City State

Has your pet had any previous surgeries, ongoing medical conditions, or recent diagnostic tests anywhere other than Johnston Animal Hospital?(Required)

No, my pet has only been seen at Johnston Animal Hospital

Yes, my pet has been seen at another facility & received a diagnosis &/or treatments

Do you have copies of your pet’s medical history from the previous facility?(Required)

Yes

Please upload your pet’s medical history from the previous facility below.(Required)

Max. file size: 256 MB.

Do you give Johnston Animal Hospital permission to contact the facility for your pet's medical history.(Required)

If you select no, then your pet will need to restart all vaccine series unless medical history is provided from another veterinary facility.

Yes

Facility Name(Required)

We will contact the facility for your pet’s medical history.

Facility's Phone Number(Required)

Facility's Address(Required)

Street Address City State

What medications is your pet taking? Please document dose and frequency.(Required)

Please include all over the counter medications and herbal remedies.

Does your pet live indoors, outdoors, or both?(Required)

Indoors Only

Outdoors Only

Inside & Outside to use the bathroom only

50/50

Is your pet fully house trained?(Required)

Yes

In Training

Does your pet get car sick?(Required)

Yes – Everytime

Yes – Occasionally

Please explain (Excessive drooling, vomit, loose bowels, etc.)(Required)

Has your pet traveled recently?(Required)

Yes

Where, when & how long of a stay?(Required)

How has your pet's appetite been?(Required)

Normal/Good

Wanting more food than given

Poor – Not eating

How long have you noticed change in your pet's appetite?(Required)

What brand and specific type/formula of food do you currently feed your pet?(Required)

(e.g., Purina – ProPlan Sport Performance, Purina – Weight Management)

How often do you feed your pet?(Required)

Once Daily

Twice Daily

Three Times Daily

Free Feed

How much do you feed your pet at each feeding?(Required)

If you were to say “one cup,” does that mean one standard 8oz measuring cup per feeding, or one solo cup of food at each feeding?

How has your pet's water consumption been?(Required)

Normal

Low

Excessive

Please share how long have you noticed the change in your pet's water consumption.(Required)

Does your pet eat any raw meat?(Required)

This includes your pet being fed raw meat or your pet possibly eatting deceased wildlife.

Yes

Uncertain

Please explain what raw meat(s) your pet has consumed.(Required)

Does your pet eat or drink any raw or unpasteurized milk or other dairy products?(Required)

Yes

Uncertain

Please explain what raw or unpasteurized milk your pet has consumed.(Required)

Have you noticed any changes in your pet’s energy level or mental status?(Required)

Yes

Please explain:(Required)

Is your pet’s energy lower or higher than normal?

Have you noticed any fleas or ticks on your pet?(Required)

Fleas Only

Ticks Only

Fleas and Ticks

Do you struggle to remember to give your pet their flea & tick prevention? There is an injectable flea & tick prevention for dogs. One injection protects your dog for a whole year! Are you interested in learning more?(Required)

Yes, I would like to learn more about injectable prevention for my pet

No, I would not like to learn more about injectable prevention for my pet

Have you seen any worms in your pet’s stool?(Required)

Yes

Uncertain

Have you noticed your pet scooting on their hind end?(Required)

Yes

Uncertain

Are you aware of any masses on your pet?(Required)

Yes

Uncertain

Please explain where you have noticed any masses:(Required)

Have you seen any recent vomiting, diarrhea, or other gastrointestinal problems with your pet?(Required)

Yes

Uncertain

Please explain the vomiting, diarrhea, or other gastrointestinal problems you have noticed with your pet, and for how long?(Required)

Have you seen any recent coughing, sneezing, or other respiratory problems with your pet?(Required)

Yes

Uncertain

Please explain the coughing, sneezing, or other respiratory problems you have noticed with your pet, and for how long?(Required)

Have you seen any recent itchiness, scratching, fur loss, or other skin problems with your pet?(Required)

Yes

Uncertain

Please explain the itchiness, scratching, fur loss, or other skin problems you have noticed with your pet, and for how long?(Required)

Have you seen any recent lameness or other musculoskeletal problems with your pet?(Required)

Yes

Uncertain

Please explain the recent lameness or other musculoskeletal problems you have noticed with your pet, and for how long?(Required)

Has your pet been exposed to any of the following? (Birds, dairy cattle, other animals either domestic or wild, or a person employed in the poultry or dairy industry)(Required)

Birds

Dairy Cattle

Other animals either domestic or wild

A person employed in either the poultry industry or the dairy industry

None of the above

Are there any additional concerns about your pet that you would like to discuss today?

Signature

Medical History Questionnaire

Medical History Questionnaire

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