Grove City Veterinary Hospital

4350 Grove City Rd.
Grove City, OH 43123

(614)875-4321

www.grovecityvet.com

New Visit History Form

Client Name (required)
First Name (required)
Last Name (required)
Pet Name (required)
First Name (required)
Last Name (required)
Appointment date and time: (required) :
I will be in this vehicle:

Best phone number for today's visit: (required)
Phone TypePhone Number (required)
Are you (the owner) or anyone living in your home quarantined because of COVID-19 or showing related symptoms? (required)

Yes
No


Primary Reason for Appointment (please be as detailed as possible) (required)

What brand of Heartworm Prevention is your pet on?

When was the last dose of Heartworm and Flea/Tick prevention given?

Please list all medications and supplements (including over the counter) that your pet is taking:

Do you need any medication refills today? If so, please list the name of the medication and amount needed.

Is your pet experiencing any of the following (check as many as apply):
Weight loss or Trouble Eating
Vomiting
Diarrhea
Coughing
Sneezing
Limping
Trouble moving around
Behavior concerns
Please select your pet's energy level:

Normal
Increased
Decreased


What brand of food do you feed your pet?

How much food and how often do you feed your pet?

What additional treats, snacks, or human food does your pet receive? Please be specific and indicate frequency.

Patient's appetite

Normal
Increased
Decreased


Water intake/drinking

Normal
Increased
Decreased


Patient's urination habits
Normal
Straining
Decreased
Blood present
Increased
Dark
Cloudy
Strong/Foul odor
Please list all of the places where your pet goes:
Fenced in yard
Yard that isn't fenced
Farm
Hiking, Camping or Swimming
Boarding
Grooming
Doggy DayCare
Indoor cat
Outdoor cat
Indoor/outdoor cat
Hunting
Leash walks
Visit friends and family
Any previous patient history that we should be aware of?

Would you like to ask the veterinarian anything or add any additional information?

What are your pet's favorite treats?

Has your pet ever been prescribed medications to help with a veterinary visit in the past? If so, what medications were they and what kind of result did you experience?

How would you describe your pet's reaction to going to the veterinary hospital?
Eager and Excited
Subdued
Reluctant
Somewhere in between
Check any situations listed below that your pet has shown avoidance or dislike of in the past. You can add additional comments at the end of this form.
Getting in their carrier or the car
Entering the Veterinary Hospital
Other pets and/or people passing by while in the reception/check-in
Waiting with other people and animals in the waiting area
Being approached by veterinary staff
Getting on the scale for a weight
Hearing the doorbell, overhead intercom, or phones ringing
Sounds coming from the back areas of the practice
Going into the exam room
Being put up on the table for examination
Having direct eye contact with the technician and/or veterinarian
Loud voices during examination
Having a rectal temperature taken
The use of instruments such as the stethoscope or otoscope (to look into the ears)
Being taken out of the exam room for procedures
How and where does your pet travel in the car? (carrier, seatbelt, loose, ect.)

How does your pet behave in the car?

Does your pet show any signs of nausea with car travel, such s drooling or vomiting?

How would you describe your pet around other animals and people?

Does your pet have any sensitive areas that he does not like to have touched or examined by your or others?

Are there any procedures your pet has not liked having performed at the veterinary hospital in the past or that seemed difficult for you or the staff to do? (Nail trims, temperature, ear exam, blood draw, ect.)

Does your pet like to play with toys? If so what kinds?

Anything else you would like us to know?


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