arrow_back Back to Dentistry and Oral Surgery Dentistry and Oral Surgery Patient History Form Patient history form Complete no later than 48 hours before your scheduled appointment. "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Client Name First Last Patient NameCurrent Veterinarian First Last Current Veterinarian's ClinicCurrent ConcernsWhat are your current concerns regarding your pet’s oral health?*Do you have specific goals for your pet’s oral health?*Dental HistoryWhat food does your pet eat?*Include brand, amount, and frequency.Does your pet chew when they eat?* Yes No I don’t know Has your pet's chewing (of food) changed in the last six months?* Yes No I don’t know Does your pet favor one side when chewing?* Yes No I don’t know What treats do you give?*Include brand, amount, and frequency.What non-food items does your pet chew?*For example, toys, treats, bones, antlers, etc.What toys does your pet play with using their mouth?*What oral symptoms have you seen at home?*What at-home dental care are you currently performing (if any)?*For example, toothbrushing, dental diet, dental chews, etc.Does your pet seem to be in pain or discomfort relating to their mouth?* Yes No I don’t know Does your pet groom normally?Cats only. Yes No I don’t know Does your pet receive anesthesia-free dentistry?* Yes No I don’t know When was this most recently performed? MM slash DD slash YYYY When was the most recent time your pet had anesthetized veterinary dental care? MM slash DD slash YYYY Did they have radiographs (x-rays) performed of their teeth? Yes No I don’t know Were there any dental extractions or other dental surgeries performed? Yes No I don’t know Medical HistoryWhat medical conditions does your pet currently have (that you know of)?What medications is your pet currently taking?Include medication name, dosage, and frequency. Include any heartworm and flea/tick medication.Has your pet had any change in their water consumption in the last six months?* Yes No I don’t know Has your pet had any increase in urination in the last six months?*Frequency, having accidents inside when they didn’t used to, etc. Yes No I don’t know Has your pet had any change in their bowel movements?*Stool consistency, frequency, etc. Yes No I don’t know Has your pet had any behavioral changes in the last 12 months?*Sleeping more, “slowing down,” abnormal behavior, etc. Yes No I don’t know Has your pet had any changes in their exercise tolerance in the last 12 months?* Yes No I don’t know Does your pet cough?* Yes No I don’t know How often?*Does your pet sneeze?* Yes No I don’t know How often?*Does your pet vomit?* Yes No I don’t know How often?*Does your pet have any allergies (to medication or food)?* Yes No I don’t know Does your pet ever go outside?Cats only. Yes No I don’t know Veterinary HistoryWhen was the most recent time your pet had a wellness appointment with your regular vet? MM slash DD slash YYYY When was the most recent time your pet had routine bloodwork (complete blood count and biochemical profile)? MM slash DD slash YYYY OtherIs there anything else we should know about your pet prior to your visit?
