Patient Health History Form

Thank you for taking the time to complete the form below prior to your pet’s appointment. We look forward to seeing you and your pet soon!
Pet Owner’s Name*
First Last
Phone Number*
Email*
Patient Name*
Date*
Date Format: MM slash DD slash YYYY
Is your pet eating and drinking normally?*
- Yes
- No
Please describe symptoms and duration:*
What diet is your pet currently on?*
Has your pet been experiencing vomiting or diarrhea?*
- Yes
- No
Please describe symptoms and duration:*
Is your pet coughing or sneezing?*
- Yes
- No
Please describe symptoms and duration:*
Is your pet currently taking a flea/tick preventative?*
- Yes
- No
Please list the product name and frequency given:*
Is your pet currently taking a heartworm preventative?*
- Yes
- No
Please list the product name and frequency given:*
Is your pet currently taking prescription medication(s)?*
- Yes
- No
Please list the medication name(s), frequency given, and prescriber’s name:*
Please list the condition for which your pet’s medication was prescribed:*
Do you need medication refills?*
- Yes
- No
Please list the medication name(s), frequency given, and prescriber’s name:*
Does your pet have anxiety?*
- Yes
- No
Please describe symptoms and activities surrounding anxiety episodes:*
Have you noticed your pet behaving abnormally recently?*
- Yes
- No
Please describe symptoms and duration:*
Does your pet spend time scratching/licking/chewing their skin/fur?*
- Yes
- No
Please describe symptoms and duration:*
Does your pet experience stiffness/soreness?*
- Yes
- No
Please describe symptoms and duration:*
Have you noticed any new lumps or growths on your pet?*
- Yes
- No
Please describe describe the location and when the change was first noticed:*
What is your pet’s typical environment (i.e. stays at home, visits local dog parks, attends daycare, travels frequently)?*
Are you planning to board your pet in the near future?*
- Yes
- No
Please list any additional health history you’d like to share:*
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Contact Information

880 West Long Lake Road
Bloomfield Hills, MI 48302

Phone: 248-642-2050
Fax: 248-642-5438
Email: [email protected]
*All emails will be responded to within 24-48 business hours*

Appointment Hours
Mon-Fri: 8:00AM – Noon & 2PM – 4:30PM
Sat: 8:30 AM – 11:30

Hours of Operation
Mon-Fri: 8:00AM – 5:00PM
Sat: 8:00 AM – Noon
Sun: Closed

After-Hours Emergency Vet Clinics

Oakland Veterinary Referral Services
(248) 334-6877
1400 S Telegraph Rd.
Bloomfield Hills, MI 48302

Blue Pearl Emergency – Southfield
(248) 354-6640
29080 Inkster Road
Southfield, MI 48034

Blue Pearl Emergency – Auburn Hills
(248) 371-3713
3412 East Walton Blvd.
Auburn Hills, MI 48326

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Patient Health History Form

Thank you for taking the time to complete the form below prior to your pet’s appointment. We look forward to seeing you and your pet soon!

Contact Information

After-Hours Emergency Vet Clinics