Exam History Form | Old Mill Veterinary Hospital

Please have this form completed before coming to the hospital. Your pet will be brought into the hospital by a team member, the doctor will do an exam and any questions / conversations will be by phone. Please have a cell phone ready and the number of that phone on this form. Payment of services will be curbside as well, and expected after this visit is complete

Curbside Appointment – Please arrive 10mins before your appointment time

Park – Please park in one of our numbered parking spaces.

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.

Face coverings – For your safety and the safety of our team members, please have a face covering on properly during the transfer of your pet, when handing off samples, or picking up medications and food.

If requested, please have a fecal sample and/or urine sample available

Name*

First

Last

Pet's Name*

Phone*

Date*

Please check here if you require a printed treatment plan with cost estimate

Check Here

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

Has your pet had any sneezing?*

Yes

Does your pet have any nasal discharge?*

Yes

If yes what color and which nostril(s)?*

Has your pet been vomiting?*

Yes

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

Has your pet had diarrhea?*

Yes

Does your pet's stool look normal in color?*

Yes

If no, is it black or bloody?*

Has your pet been drinking more?*

Yes

Has your pet been urinating more?*

Yes

Have you seen your pet's urine?*

Yes

If so what was the color and amount?*

What brand/variety of food are you feeding your pet?*

How much per day?*

Has your pet's appetite changed?*

Yes

If so describe how?*

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

Any change in diet?*

Yes

If yes, when and what did you change?*

Is your pet lethargic (not active)?*

Yes

If yes, how long?*

Is your pet here because it was limping?*

Yes

If so which leg and how long?*

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

Has your pet cried out?*

Yes

If so, what was your pet doing when this occured?*

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

Yes

Which eye, describe any drainage or symptoms*

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

Yes

Which ear, describe any discharge or symptoms*

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

Yes

If yes, describe*

Would you like your pets nails trimmed while here?*

Yes

Comment if any concerns with the nails

Would you like your pets anal glands emptied?*

Yes

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

Are there any new lumps or bumps you have found?*

Yes

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

Please use the rest of the box 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

Phone*

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