Pre-Visit Patient History Form

Thank you for completing this form prior to each of your pet’s appointments for examinations and re-evaluations, even if your pet’s condition has not changed since his or her last visit. The information you provide will help streamline your pet’s vet visit as we continue curbside care to keep everyone safe and healthy during the COVID-19 pandemic.

CANINE AND FELINE PATIENTS

Today's Date *

Patient Name *

Species *

Age/D.O.B.

Gender *

Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unknown

Color

Breed

Appointment Date & Time

Date

Time

Who will be bringing your pet to their appointment? *

First

Last

Vehicle (color/make/model)

Best phone number to reach this person during this appointment *

(Our veterinary team will use this phone number to communicate with you during your pet’s appointment)

Is this person authorized to make medical decisions for this patient? *

If no, please list the name and number of the person we should call discuss all medical findings and recommendations.

Which type of communication would you prefer during this appointment: *

Phone only
Video conference

(go to https://zoom.us to download the app on your mobile device prior to your appointment)

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

If yes, please tell us more: *

Do you have pet insurance for this pet? *

Insurance carrier & policy #: *

Which flea/tick medication do you use?

Last Date Given

Which heartworm medication do you use?:

Last Date Given

List all other medications and supplements your pet is currently taking (medication/supplement name, dose, frequency):

Do you need refills of any medications/supplements today?

Medication Name *

Quantity *

Refill Location *

Gladstone Veterinary Clinic
Other

If other, please specify *

What are you feeding? *

Wet food only
Dry food only
Mixture of wet & dry food
People food
Raw diet
Home-cooked diet
Treats/other

Wet Food - Brand(s)/formulation(s) of pet food and amount/frequency

Dry Food - Brand(s)/formulation(s) of pet food and amount/frequency

Mixture of wet & dry food - Brand(s)/formulation(s) of pet food and amount/frequency

People Food - What ingredients do you feed? And amount/frequency

Raw Diet - Brand(s)/formulation(s) of pet food and amount/frequency

Home-cooked Diet - What ingredients do you feed? Amount/frequency? Who formulated this diet for you?

Treats/other - What treats or other food do you feed? Amount/Frequency?

Do you need refills of any prescription diets? *

If yes, list brand, formulation, amount *

How is your pet’s appetite? *

Normal
Increased
Decreased

Comments

How is your pet’s thirst level? *

Normal
Increased
Decreased

Comments

Has your pet had any nausea, vomiting or regurgitation? *

Please describe the color, consistency, frequency, duration

Is it possible your pet may have eaten/ingested:

Garbage
Compost
Mushrooms
Marijuana/Other Drugs
Toys or other objects
Human or veterinary medications (accidentally)

If Other drugs, please describe: *

How are your pet’s bowel movements? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration

Does your pet experience flatulence (gas)? *

Please describe frequency and any comments

How is your pet’s urination? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration, any urinary accidents

Has your cat urinated or defecated somewhere in the house, other than in the litterbox in the past 3 months? *

How many cats are in your household? *

How many litterboxes do you have? *

How is your pet’s energy/activity level? *

Normal
Abnormal

Energy level has *

Increased
Decreased

Comments

Please check which, if any, your pet has experienced in the past 2 weeks

Coughing
Sneezing

Please explain frequency, duration, and description of cough *

Please explain frequency, duration, and description of sneezes *

Has your pet ever had a seizure? *

Please explain frequency, duration, and description of seizure(s) *

Approximate date of last seizure

Does your pet have any behavior issues? *

If yes, please describe: *

Do you provide any home dental care? *

Type/frequency?

What is/are your pet’s lifestyle/social risks (including pre-pandemic activities): *

None
Grooming
Boarding
Travel outside of the Portland metro area
Dog Park
Doggy Daycare
Obedience Training

Where? *

What is/are your pet’s lifestyle/social risks (including pre-pandemic activities): *

None
Grooming
Boarding
Travel outside of the Portland metro area
Indoor only
Indoor/outdoor
Outdoor only

Where? *

Has your pet been prescribed any anti-anxiety medications to help decrease fear, anxiety, or stress during vet visits? *

If yes, please list medication name(s)

Please pre-medicate your pet as directed prior to his/her vet visit.

Is there anything else you would like to discuss during your pet’s visit today? *

Please explain:

APPOINTMENT PROCEDURES:

I understand that access to the Gladstone Veterinary Clinic building is limited to employees and pet patients only at this time due to the COVID-19 pandemic. For everyone’s safety, I understand that I must wear a facemask at all times during any direct interactions with the Gladstone Veterinary Clinic team. *

I have read and understand

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone. *

I have read and understand

Website

Small Mammal PATIENTS

Today's Date *

Patient Name *

Age/D.O.B.

Gender *

Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unknown

Species *

Color

Breed

Appointment Date & Time

Date

Time

Who will be bringing your pet to their appointment? *

First

Last

Vehicle (color/make/model)

Best phone number to reach this person during this appointment *

(Our veterinary team will use this phone number to communicate with you during your pet’s appointment)

Is this person authorized to make medical decisions for this patient? *

If no, please list the name and number of the person we should call discuss all medical findings and recommendations.

Which type of communication would you prefer during this appointment: *

Phone only
Video conference

(go to https://zoom.us to download the app on your mobile device prior to your appointment)

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

If yes, please tell us more: *

Do you have pet insurance for this pet? *

Insurance carrier & policy #: *

Which flea prevention do you use?

Last Date Given

List all other medications, vitamins, and supplements your pet is currently taking (medication/vitamin/supplement name, dose, frequency):

Do you need refills of any medications/supplements today?

Medication Name *

Quantity *

Refill Location *

Gladstone Veterinary Clinic
Other

If other, please specify *

What are you feeding? *

Pellets
Other
Hay
Vegetables
Fruits
Treats/other

Pellets - Brand(s)/type(s) and amount/frequency

Other - Brand(s)/type(s) and amount/frequency

Hay - Type(s) and amount/frequency

Vegetables - Type(s) and amount/frequency

Fruits - Type(s) and amount/frequency

Treats/other - Type(s) and amount/frequency

Water Source:

How is your pet’s appetite? *

Normal
Increased
Decreased

Comments

How is your pet’s thirst level? *

Normal
Increased
Decreased

Comments

Has your pet had any nausea, vomiting or regurgitation? *

Please describe the color, consistency, frequency, duration

Is it possible your pet may have eaten/ingested:

Garbage
Compost
Mushrooms
Marijuana/Other Drugs
Toys or other objects
Human or veterinary medications (accidentally)

If Other drugs, please describe: *

How are your pet’s bowel movements? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration

How is your pet’s urination? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration, any urinary accidents

How is your pet’s energy/activity level? *

Normal
Increased
Decreased

Comments

Please check which, if any, your pet has experienced in the past 2 weeks

Coughing
Sneezing

Please explain frequency, duration, and description of cough *

Please explain frequency, duration, and description of sneezes *

Has your pet ever had a seizure? *

Please explain frequency, duration, and description of seizure(s) *

Approximate date of last seizure

Does your pet have any behavior issues? *

If yes, please describe: *

Please describe your pet's enclosure material: *

Glass
Wire
Screen
Wood
Other

If other, please describe: *

Size:

Substrate/bedding type:

How frequently is bedding changed?

Disinfectant used to clean enclosure:

Location of enclosure:

What other animals share this enclosure?

Allowed to roam outside of enclosure? *

Where? *

How frequently? *

How long? *

Please upload photos of enclosure

Click or drag files to this area to upload. You can upload up to 5 files.

Is there anything else you would like to discuss during your pet’s visit today? *

Please explain:

APPOINTMENT PROCEDURES:

I have read and understand

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone. *

I have read and understand

Name

Avian PATIENTS

Today's Date *

Patient Name *

Age/D.O.B.

Gender *

Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unknown

Species *

Color

Breed

Appointment Date & Time

Date

Time

Who will be bringing your pet to their appointment? *

First

Last

Vehicle (color/make/model)

Best phone number to reach this person during this appointment *

(Our veterinary team will use this phone number to communicate with you during your pet’s appointment)

Is this person authorized to make medical decisions for this patient? *

If no, please list the name and number of the person we should call discuss all medical findings and recommendations.

Which type of communication would you prefer during this appointment: *

Phone only
Video conference

(go to https://zoom.us to download the app on your mobile device prior to your appointment)

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

If yes, please tell us more: *

Do you have pet insurance for this pet? *

Insurance carrier & policy #: *

List all other medications, vitamins, and supplements your pet is currently taking, including hormone injections (medication/vitamin/supplement name, dose, frequency):

Do you need refills of any medications/supplements today?

Medication Name *

Quantity *

Refill Location *

Gladstone Veterinary Clinic
Other

If other, please specify *

What are you feeding? Please be specific. *

Seed
Pellets
Vegetables
Fruits
Treats
Other

Seed - Brand(s)/type(s) and amount/frequency

Pellets - Brand(s), Flavor/Type(s) and amount/frequency

Vegetables - Type(s) and amount/frequency

Fruits - Type(s) and amount/frequency

Treats - Brand(s)/Type(s) and amount/frequency

Other - Type(s) and amount/frequency

Water Source:

How is your pet’s appetite? *

Normal
Increased
Decreased

Comments

How is your pet’s thirst level? *

Normal
Increased
Decreased

Comments

Has your pet had any nausea, vomiting or regurgitation? *

Please describe the color, consistency, frequency, duration

Is it possible your pet may have eaten/ingested:

Garbage
Compost
Mushrooms
Marijuana/Other Drugs
Toys or other objects
Human or veterinary medications (accidentally)

If Other drugs, please describe: *

How are your pet’s droppings? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration

How is your pet’s energy/activity level? *

Normal
Increased
Decreased

Comments

Is your bird allowed to roam outside of enclosure? *

Where? *

How frequently? *

How long? *

Please describe your bird's enclosure size: *

Material:

Substrate:

How frequently is substrate changed?

Where is enclosure located?

Inside
Outside

Where?

What toys/enrichment do you have for your bird?

Do you have other birds?

Number/types:

What other birds share the enclosure with this pet?

Please upload photos of enclosure

Click or drag files to this area to upload. You can upload up to 5 files.

Please check which, if any, your pet has experienced in the past 2 weeks

Coughing
Sneezing

Please explain frequency, duration, and description of cough *

Please explain frequency, duration, and description of sneezes *

Has your pet ever had a seizure? *

Please explain frequency, duration, and description of seizure(s) *

Approximate date of last seizure

Does your pet have any behavior issues? *

If yes, please describe: *

Is there anything else you would like to discuss during your pet’s visit today? *

Please explain:

APPOINTMENT PROCEDURES:

I have read and understand

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone. *

I have read and understand

Message

Reptile/Amphibian PATIENTS

Today's Date *

Patient Name *

Age/D.O.B.

Gender *

Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unknown

Species *

Color

Breed

Appointment Date & Time

Date

Time

Who will be bringing your pet to their appointment? *

First

Last

Vehicle (color/make/model)

Best phone number to reach this person during this appointment *

(Our veterinary team will use this phone number to communicate with you during your pet’s appointment)

Is this person authorized to make medical decisions for this patient? *

If no, please list the name and number of the person we should call discuss all medical findings and recommendations.

Which type of communication would you prefer during this appointment: *

Phone only
Video conference

(go to https://zoom.us to download the app on your mobile device prior to your appointment)

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

If yes, please tell us more: *

Do you have pet insurance for this pet? *

Insurance carrier & policy #: *

List all other medications, vitamins, and supplements your pet is currently taking (medication/vitamin/supplement name, dose, frequency):

Do you need refills of any medications/supplements today?

Medication Name *

Quantity *

Refill Location *

Gladstone Veterinary Clinic
Other

If other, please specify *

Length of time owned: *

Was this pet *

Captive
Wild-caught

Where acquired: *

What are you feeding? *

Insects
Vegetables
Fruits
Other
Treats/other

Please specify *

Gut-loaded
Not gut-loaded
Unknown

Insects - Type(s) and amount/frequency

Vegetables - Type(s) and amount/frequency

Fruits - Type(s) and amount/frequency

Organic? *

Other - Brand(s)/type(s) and amount/frequency

Treats/other - Type(s) and amount/frequency

Water Source:

How is your pet’s appetite? *

Normal
Increased
Decreased

Comments

How is your pet’s thirst level? *

Normal
Increased
Decreased

Comments

Has your pet had any nausea, vomiting or regurgitation? *

Please describe the color, consistency, frequency, duration

Is it possible your pet may have eaten/ingested:

Garbage
Compost
Mushrooms
Marijuana/Other Drugs
Toys or other objects
Human or veterinary medications (accidentally)

If Other drugs, please describe: *

How are your pet’s droppings? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration

How frequently handled is your pet? *

Daily
Occasionally
Never

How is your pet's shedding? *

Normal
Abnormal

Please describe frequency and give date of last shed:

How is your pet’s energy/activity level? *

Normal
Increased
Decreased

Comments

Please check which, if any, your pet has experienced in the past 2 weeks

Coughing
Sneezing

Please explain frequency, duration, and description of cough *

Please explain frequency, duration, and description of sneezes *

Has your pet ever had a seizure? *

Please explain frequency, duration, and description of seizure(s) *

Approximate date of last seizure

Does your pet have any behavior issues? *

If yes, please describe: *

Please describe your pet's enclosure material: *

Glass
Wire
Screen
Wood
Other

If other, please describe: *

Size:

Substrate: *

Sand
Moss
Algae
Other

If other, please describe: *

Location of enclosure:

Humidity:

Lighting: *

UVA
UVB
Full-spectrum

How frequently changed?

Last date changed?

How long is light on per day?

Heating sources:

Please specify temperature range from high to low, including basking:

Disinfectant used to clean enclosure:

Frequency of cleaning:

Allowed to roam outside of enclosure? *

Where? *

How frequently? *

How long? *

What other animals share this enclosure?

Please upload photos of enclosure

Click or drag files to this area to upload. You can upload up to 5 files.

Is there anything else you would like to discuss during your pet’s visit today? *

Please explain:

APPOINTMENT PROCEDURES:

I have read and understand

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone. *

I have read and understand

Phone