Dog/Cat History Questions Form Dog/Cat History Questions Pet's Name * Owner's Last Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Cell Phone to Contact Today * Email * Have you noticed any lumps, bumps, growths, non-healing sores or swellings? * Yes No Have you noticed any coughing, sneezing, or difficulty breathing? * Yes No Has your pet been vomiting or having diarrhea? * Yes No Does your pet have any ear problems? (head shaking, scratching, odor, sensitivity, discharge) * Yes No Have you noticed any excessive itching or scratching? * Yes No Does your cat urinate or defecate outside of the box? * Yes No N/A Do you take your pet to a groomer, dog park, day care, boarding facility, or stores where it could have contact with other dogs? * Yes No What diet do you feed your pet? (Brand, amount, wet/dry?) * What treats and table food do you give your pet? And how much? * What activities do you do with your pet for exercises? * What dental care do you provide at home? * Which flea and tick and heartworm preventative do you use? When did you give your last dose? * Do you need any medications refilled today? Heartworm/ flea meds? * Do you need your pets ears cleaned, nails trimmed, or anal glands expressed?(specify which service.) * Has your pet had bloodwork in the past 12 months? * Yes No Does your pet have any health or behavior concerns you want to discuss with Dr. Culpepper today? * Yes No Are there any medical conditions you are aware of with your pet that we should be notified of? Allergies? Vaccine reactions? * Submit If you are human, leave this field blank.
