New patient Form PDF version – if preferred "*" indicates required fields Client InfoClient Status New Client Returning Client Appointment Status Appointment scheduled No appointment scheduled yet Date of Appointment MM slash DD slash YYYY Name* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Preferred Contact Method* Phone Email Patient InfoPet's Name* Species*--DogCatHorseRabbitOtherBreed (if applicable) Sex*--MaleMale NeuteredFemaleFemale SpayedBirth Date/Approx. Age* Concerns*What is your reason for seeking treatment for your pet?Musculoskeletal EvaluationTell us if your pet has any problems with the following:Maintaining standing position* No problem A little Quite a bit Severe Impossible Walking* No problem A little Quite a bit Severe Impossible Running* No problem A little Quite a bit Severe Impossible Jumping* No problem A little Quite a bit Severe Impossible Positioning to urinate/defecate* No problem A little Quite a bit Severe Impossible Getting up* No problem A little Quite a bit Severe Impossible Lying Down* No problem A little Quite a bit Severe Impossible Sitting* No problem A little Quite a bit Severe Impossible Rolling over* No problem A little Quite a bit Severe Impossible Climbing stairs* No problem A little Quite a bit Severe Impossible Descending stairs* No problem A little Quite a bit Severe Impossible Getting on/off furniture* No problem A little Quite a bit Severe Impossible Dragging foot/feet* No problem A little Quite a bit Severe Impossible This problem is worse... In the am In the pm Cold weather Hot weather Rainy weather Seasonal After exercise Before exercise Other Describe Severity ScoresPain Score*0 = best, 10 = worstN/A012345678910Anxiety Score*0 = best, 10 = worstN/A012345678910Itching Score*0 = best, 10 = worstN/A012345678910When is the itching the worst? Morning Evening Cold Weather Hot Weather Seasonally Quality of Life Score*0 = worst, 10 = best012345678910MedicationsTell us about any medications or supplements that your pet has taken for their condition.Medication 1 How much did/does it help?--A great dealSomewhatLittleNot at allMedication 2 How much did/does it help?--A great dealSomewhatLittleNot at allMedication 3 How much did/does it help?--A great dealSomewhatLittleNot at allMedication 4 How much did/does it help?--A great dealSomewhatLittleNot at allMedication 5 How much did/does it help?--A great dealSomewhatLittleNot at allGeneral HabitsAppetite* Normal Increased Decreased Finicky Ravenous Water Intake* Normal Drinks very little Always thirsty Urination* Normal Incontinent/Leakage Bloody Strong odor Stool* Normal Dry Loose Bloody Incontinent/Leakage SymptomsDoes your pet display any of the following symptoms?* Vomiting Diarrhea Cough Insomnia Panting Preference for heat/cold None of the above Symptom DescriptionLifestyleDoes your animal have any specific needs?Does your pet co-mingle with other animals?* No Yes, at home Yes, at a kennel Yes, at the groomer Yes, at the dog park Yes, at training/events How does your pet behave around other animals?* Friendly Aggressively Shy Scared Aloof How does your pet behave around people?* Friendly Aggressively Shy Scared Aloof Is there anything that makes your pet nervous?Describe your pet's energy level*Has your pet ever been diagnosed with cancer?*--noyesExplainAny other information you would like to share about your petWhat is your current, primary goal for your pet?* Δ
