Owner's First Name:(Required)

Owner's Last Name:(Required)

Owner's Phone Number:(Required)

Owner's Email:(Required)

Pet's Name:(Required)

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

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

Has your pet had any previous surgeries, ongoing medical conditions, or recent diagnostic tests beyond those performed at Johnston Animal Hospital?(Required)

If yes, please explain and include where the procedure(s) were performed so records can be obtained.

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

This also includes over the counter calming chews etc.

Is your pet fully house trained?(Required)

Yes

In Training

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

Indoors Only

Outdoors Only

Inside & Outside to use the bathroom only

50/50

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

If yes please explain

Has your pet traveled recently? If yes, where, when & how long of a stay?(Required)

If yes please explain

Does your pet get car sick?(Required)

If yes please explain (Excessive drooling, vomit, loose bowels etc)

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

Normal/Good

Wanting more food than given

Poor – Not eating

What are you feeding your pet?(Required)

How often do you feed your pet?(Required)

How much do you feed your pet?(Required)

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

If yes please explain if your pet’s energy has be low or higher than normal

Does your pet eat any raw meat?(Required)

Yes

Uncertain

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

Yes

Uncertain

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

Fleas Only

Ticks Only

Fleas and Ticks

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

If yes, please explain where

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

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

Normal, low, excessive & how long have you noticed the change

Have you noticed any changes in your pet’s urination?(Required)

If yes please explain

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

If yes please explain

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

If yes please explain

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

If yes please explain

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

If yes please explain

Has your pet been exposed to any of the following? (Please select all that apply)(Required)

Birds

Dairy Cattle

Other animals such as domestic or wild

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

None of the above

History Intake Form

History Form for Your Upcoming Appointment

History Intake Form

History Form for Your Upcoming Appointment

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