Curbside History Form

Name*

First Last

Pet's Name*

Cell Phone*

Date*

Curbside Appointment: Please arrive 10mins before your appointment time
Park: Please let us know where you have parked, the make, color, and model of your car.
Notifying us of your Arrival: Please call our office once you have arrived.
Pet Prepared: Please have your pet on a leash or in a carrier before we come to the car.

If your pet is scheduled for a routine annual exam, we recommend yearly blood work and viral screening. Fecals checked twice yearly and vaccines due updated. We will provide an estimate of what we have in our records that is needed for your pet for you to review when we come to your car.
Please bring a fecal and urine sample, so if needed it is available.

Briefly describe the reason your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.*

Has your pet had any coughing ?

Yes
No

Has your pet had any sneezing ?

Yes
No

Does your pet have any nasal discharge?

Yes
No

If yes what color and which nostril(s)?

Has your pet been vomiting?

Yes
No

If your pet has been vomiting when was the last time and describe the vomit.

Has your pet had diarrhea?

Yes
No

Does your pet's stool look normal in color?

Yes
No

If no, is it black or bloody?

Has your pet been drinking more?

Yes
No

Has your pet been urinating more?

Yes
No

Have you seen your pet's urine?

Yes
No

If so what was the color and amount?

Has your pet's appetite changed?

Yes
No

If yes please describe how.

When was the last time you saw a bowel movement and what did it look like?

Any change in diet?

Yes
No

If yes, when and what did you change?

Is your pet lethargic (not active)?

Yes
No

If yes, for how long?

Is your pet here because it is limping?

Yes
No

If so which leg and how long?

Please list all medications your pet is on and when they were last given:

Has your pet cried out?

Yes
No

If so what was your pet doing when this occurred?

Does your pet have a problem with one or both of its eyes?

Yes
No

Which eye, describe any drainage or symptoms.

Does your pet have a problem with one or both of its ears?

Yes
No

Which ear, describe any discharge or symptoms.

Do you have a concern with your pet's teeth?

Yes
No

If yes, describe.

Would you like your pet's nails trimmed while here?

Yes
No

Comment if any concerns with the nails.

Would you like your pet's anal glands emptied?

Yes
No

Comment if any concerns with them, any scooting or licking?

Are there any new lumps or bumps you have found?

Yes
No

If so, where are they and how long have they been present?

Please use this area to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.

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