Bay Area Veterinary Specialists New Patient History

12855 Gulf Freeway Houston, TX 77034

281.464.3554

Ext 1: Surgery Department

Veterinary Surgical Group, LLP

Ext 2: Cardiology, Internal Medicine, Oncology

Veterinary Medical Specialists of Houston

Ext 3: Ophthalmology

Gulf Coast Animal Eye Clinic

New Patient History

Please help us obtain as much information about your pet as possible by completing this form. The veterinarian will review this form with you at the time of your pet’s appointment.
Pet's Name:*
Client's Last Name:*
Last
Date:*
Date Format: MM slash DD slash YYYY
Reason for visit:*
Please indicate when vaccines were most recently given:*
Date Given:
Please list any places outside the Houston area that your pet has lived or visited:*
Primary diet (brand and formulation):*
Where does your pet live?*
- Primarily indoors
- Indoors/outdoors
- Primarily outdoors
Has your pet ever had ticks?*
- Yes
- No
If yes, when?
Does your pet have any previous diagnosis of chronic disease(s)?*
- Yes
- No
If yes, please explain:
Please indicate whether your pet has experienced any of the following in the last 6-8 weeks:
Changes in appetite?*
Vomiting?*
Changes in bowel movements?*
Abnormal urination?*
Abnormal thirst?*
Coughing?*
Sneezing?*
Abnormal respiration?*
Nasal discharge?*
Any other discharge?*
Any swellings or lumps?*
Bleeding from anywhere?*
Abnormal gait or lameness?*
Fever detected by thermometer?*
Changes in attitude or activity level?*
Weight loss?*
Changes in environment?*
Exposure to toxins, pesticides, rat poison, or coumadin?*
Seizures, fainting, or collapse?*
Changes in vision, smell, or hearing?*
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