Patient History Form Please fill out this patient history form in entirety to ensure we can provide your pet with the best possible care.Other Medical HistoryIf your pet has medical history from another veterinary facility, please have them email us the records to yourpetsvet@sgvet.comPet's Name* First Last Your Name* First Last It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot or will be otherwise occupied while your pet is here, please ask us about a drop off appointment.Where can we call you at while your pet is here?*Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing or fever) in the last 14 days?YesNoHave you or someone in your home been asked by a health care professional and/or the Department of Health/CDC to quarantine in the last 14 days?*YesNoReason for your pet's visit today?*This issue began on* This issue is:*ImprovingContinuing (stabl or unchanging)WorseningHas your pet had any: Coughing Sneezing Vomiting Diarrhea New lumps or bumps Behavior changes Changes in mobility Changes in bathroom habits Other Other*My pet's appetite is:*NormalIncreasedDecreasedMy pet's thirst level is:*NormalIncreasedDecreasedMy pet's activity level is:*NormalIncreasedDecreased / lethargicMy pet's urination is:*NormalAbnormalMy pet eats*Wet food onlyDry food onlyWet and Dry MixturePeople FoodRaw DietHome Cooked DietBrand of Pet Food*If prescription diet, what formulation?How Often Is Your Pet Fed?*How Much Is Your Pet Fed PER MEAL?*In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides etc.)Has your pet's diet changed in the last 6 months?YesNoI am not sureIs it possible for your pet to have Eaten garbage Ingested toxins (rat bait, ant bait, other known toxic substances) Ingested Mushrooms Ingested Marijuana Eaten toys (part of toys missing, chewed up etc.) Eaten grain free diet for any period of time Ingested human or animal medications not intended for them or at higher doses than intended? NONE OF THE ABOVE ARE POSSIBLE Please list any medications, supplements, topical treatments your pet has received in the past month and when they were last given:When Was Your Pet's Last Dose of Heartworm Preventative?*Date Given (Please type N/A if not on a preventative)What Kind of Heartworm Preventative Do You Use?*Name of medication - put unknown if not sureWhen Was Your Pet's Last Dose of Flea/Tick Preventative?*Date Given (Please type N/A if not on a preventative)What Kind of Flea/Tick Preventative Do You Use?*Name of medication - put unknown if not sureIs Your PetIndoor OnlyMostly Indoor but Rarely to Occasionally Spends Time OutdoorsIndoor/OutdoorOutdoor OnlyOutdoor During Day/Inside At NightAre There Other Pet's In The HomeYesNoDoes Your Pet Visit the dog park Get Groomed Regularly Compete in Dog/Cat Shows Attend Obedience Training Attend Agility/Dock Diving/Search and Rescue programs etc. Board Attend Doggie Daycare Travel with you (inside state of ND) Travel with you (outside state of ND) Travel to lakes with you Is Your Pet Current On Vaccinations?*YesNoI Am Not SureMy pet's vaccines were administered last by:At Southgate Veterinary HospI Am Not Sure WhereDoes Your Pet Have A Microchip?YesNoI am not sureDoes Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?If yes, please tell us more. If no, please note N/AIs There Anything Else We Should Know About Your Pet?If yes, please tell us more. If no, please note N/AAre there pictures or video that would help us with our exam today?Is There Anything Else You Would Like To Discuss Today?Appointment ProceduresI understand the COVID-19 precautions: If I am sick, have been exposed, or have a pending test: I will reschedule my appointment or find someone whom can transport my pet.*InitialI understand that payment is due in full at the time services are rendered. This includes services authorized by another responsible party listed on my account; and/or by phone.*InitialSignature*