Patient History Form | Rockmart Animal Hospital

Welcome To Rockmart Animal Hospital

We are thrilled to welcome you as a new client at Rockmart Animal Hospital. It is our privilege to care for your beloved pet, and we look forward to supporting you both for many years to come.

Our pets rely on us to communicate their needs and concerns. We encourage you to ask any questions or share any worries you may have. Good communication is the foundation of the relationship between our clients and doctors, and it is essential for your pet’s well-being.

Providing a detailed patient history helps us with early diagnosis, prevention, and maintaining your pet’s overall wellness. Your answers allow our veterinarians and staff to create personalized treatment plans tailored to your pet’s specific needs. We appreciate your cooperation in providing this information to ensure the best possible care for your pet.

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Owner Information:

First Name*

Last Name

Phone*

Email Address*

Name of Previous Veterinary Hospital/Veterinarian

If your pet is not current with vaccines, when were they last vaccinated by a veterinarian?

In accordance with the recommendations of the Center for Disease Control, we recommend yearly heartworm testing and bi-annual screening for intestinal parasites. If your pet is due for either of these lab tests, can we perform these services during your pet’s visit?

Pet Information

Pet's Name

Species

Sex

Neutered or Spayed

What food do you currently feed your pet?

Amount & Frequency?

Does your pet eat treats?

What types of treats?

How often?

Does your pet consume table food?

Is your pet primarily indoor only? Outdoors? Or both?

Any other animals in the household?

Access to any livestock on property?

Do you board your pet?

If 'yes', how often do you board your pet?

Does pet require grooming outside home?

If 'yes', how often does pet require grooming?

Pet Medical History

Any attitude/behavior changes with your pet?

Has your pet ever had a seizure?

Does your pet have any exercise intolerance?

Any recent changes in appetite?

Has your pet been vomiting?

How often and/or when did vomiting start?

Has your pet been having diarrhea?

How often and/or when did diarrhea start?

Has your pet been sneezing/coughing?

When did these symptoms start?

Does your pet have any discharge from nose, eyes, vulva, etc.?

Does your pet have difficulty rising after lying down and/or any lameness?

Has your pet been itchy and/or signs of hair loss?

Does your pet have any growths or lumps that are concerning you?

Past History

Has your pet been microchipped?

If so, is the microchip registered?

Is your pet on flea prevention?

What type and do you give it monthly?

Is your pet on heartworm prevention?

What type of heartworm prevention?

Has your pet been exposed to ticks?

Is your pet used for hunting?

Is your pet taken camping/on outdoor trips?

Is your pet used for breeding?

Is she pregnant or is he currently standing?

Has your pet had any prior illnesses, accidents, or surgeries?

Is your pet aggressive or fearful around strangers or other’s pets?

Aside from heartworms, flea and tick preventatives, is your pet given any other medication?

Does your pet have any known allergies to any medications or food protein?

Has your pet ever had a reaction to vaccines?

If so, please list which vaccine:

Please share the reason for your pet’s appointment and what needs addressing today?

What were the first signs of the problem and how did it progress?

Were any diagnostic tests and/or treatment given by you or another veterinarian?

Payment Information

Payment for all services is due when rendered

Method of Payment*

Does Your Pet Have Health Insurance?*

Insurer’s Name

Owner Signature*

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Phone

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