Pe' General Medical History Form - ARKLE Veterinary Care, LLC

ARKLE Veterinary Care, LLC

1020 Concord Rd., SE
Smyrna, GA 30080-4206

(770)435-6700

www.arklevetcare.com

Please take a moment to fill out your pet's general medical history. If your pet has seen a veterinarian, please have all doctor's notes and vaccine history emailed or faxed over prior to your appointment. If your pet has not seen a veterinarian, please bring all paperwork you were given with you.

Thank You for choosing ARKLE Veterinary Care for your pet's health care needs.

Email to: info@arklevetcare.com
Fax Number: 770-434-4863

Pet's Medical History Form

Name (required)

First Name (required)	Last Name (required)

Pet's Name (required)

My Pet is a (required)
Dog
Cat

My pet's birth date or age is (required)

What color is your pet? (required)

1. Has your pet had any problems receiving vaccines in the past? (required)
Yes
No

1a. If yes, what symptoms did your pet have?

2. Does your pet live indoors only, outdoors only or both indoors/outdoors? (required)
Goes Indoors/Outdoors
Never Goes Outside
Never Goes Inside

2a. If your pet goes outside, is he/she?
On a leash
In a fenced yard
No leash or fenced yard

3. Does your pet go to any of the following: Grooming/Boarding/Dog Parks? (select all that apply) (required)
None
Doggie Day Care
Grooming
Dog Parks
Pet Stores
Boarding

4. What brand of food do you feed your pet? (required)

4a. Canned and/or Dry food? How much of each do you feed at each meal? (required)

4b. How often do you feed your pet? (required)
Once a day
Twice a day
Three times a day
Leave food in bowl

4c. Do you give your pet treats? If yes, what kind and how many per day? (required)

4d. Does your pet have any known food allergies? If yes, what is he/she allergic to? (required)

5. Is your pet drinking his/her normal amount of water daily? (required)
About the same
More than usual
Less than usual

6. Do you do any dental home care for your pet? (required)
None
Brush teeth
Water Additive
Dental Chews

7. What Heartworm Prevention is your pet currently on? (required)

7a. Has your pet missed any doses? If yes, how many? (required)

8. What day of the month do you give the heartworm prevention? (required)

8a. What flea prevention is your pet on? (required)

8b. Has your pet missed any doses? If yes, how many? (required)

9. What day of the month do you give the flea prevention? (required)

9a. Any other medications or supplements given? (required)

10. Will you need a refill of any medications? (required)
Yes
No

10a. If yes, which medications?

11. Any itching/scratching anywhere or shaking of the head? If yes, please indicate what and where? (required)

12. Have you noticed any changes in your pet's urination or stool (poop)? (required)
Do not see pet urinate/defecate
No changes in either
Changes in urination
Changes in stool

12b. If yes, please explain what changes you have noticed?

13. Any vomiting and/or diarrhea? (check all that apply) (required)
None
Vomiting
Diarrhea

13a. If yes, is this a new problem or a reoccurring problem?

13b. How long have you noticed symptoms? How frequently does this occur?

14. Does your pet have any of the following: Coughing/Sneezing/Watery Eyes? (check all that apply) (required)
Coughing
Sneezing
Watery Eyes
Runny Nose
None

14b. If yes, please indicate how long you have noticed symptoms?

Verify the reCAPTCHA:

Day	Open	Close
Monday and Wednesday	8:00am	5:40pm
Tuesday and Thursday	7:30am	5:40pm
Friday and Saturday	8:00am	12:00pm
Sunday	Closed	Closed

Day	Open	Close
Monday and Wednesday	8:00am	5:40pm
Tuesday and Thursday	7:30am	5:40pm
Friday and Saturday	8:00am	12:00pm
Sunday	Closed	Closed