Patient History Form - Juanita Bay Veterinary Hospital

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- Our Team
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Resources
Contact Us
- Have an Emergency?

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HAVE AN EMERGENCY?
Pay Bill Now

Instagram Twitter Youtube Facebook Yelp Store-alt

Book Appointment
Online Pharmacy
Payments

About
- Our Team
- Videos
- Blog
- Testimonials
- Specials
- Careers
- Our Location
Services
Resources
Contact Us
- Have an Emergency?

About
- Our Team
- Videos
- Blog
- Testimonials
- Specials
- Careers
- Our Location
Services
Resources
Contact Us
- Have an Emergency?

Mon – Fri: 8a – 6p
Sat: 9p – 3p
Sun: CLOSED

(425) 823-8411

11416 98th Ave NE
Kirkland, WA 98033

Mon – Fri: 8a – 6p
Sat: 9p – 3p
Sun: CLOSED

(425) 823-8411

11416 98th Ave NE
Kirkland, WA 98033

Patient History Form

URL
This field is for validation purposes and should be left unchanged.
Your Name*
First Last
Pet's Name*
Patient History
Please share your observations of your pet's condition below
Your pet’s current problem(s)
Duration and frequency of problem(s)
My pet's problem is*
- The Same
- Better
- Worse
Comments
Has a similar problem happened in the past?
My pet's appetite has*
- Not Changed
- Has Increased
- Has Decreased
Comments
What is the name of your pet's current diet?
How frequently are you feeding your pet?
What measurement of food are you giving your pet daily? (1/2 cup, 1 cup, etc.)
If you regularly feed treats, what brand/type are they?
Is your pet currently taking any medications or supplements
Please include the name of the medication or supplement as well as the dosage and frequency given.
What is your pet's travel history?
Please include details (dates and locations) of any national or international travel in the past 5 years.
Does your pet have regular access to dog parks, hiking, camping or other outdoor activity?
Does your cat have access to outdoors or other outdoor cats?
- Indoor Cat Only
- Outdoor Exposure
- Not Applicable
Patient Symptoms
Please indicate if your pet currently has any of the following symptoms.
Coughing*
- Yes
- No
Comment
Sneezing*
- Yes
- No
Comment
Weight loss*
- Yes
- No
Comment
Excessive Water Consumption*
- Yes
- No
Comment
Excessive Urination*
- Yes
- No
Comment
Vomiting*
- Yes
- No
Comment
Diarrhea*
- Yes
- No
Comment
Does Your Pet Have a Microchip
- Yes
- No
Is Your Pet on Current Parasite Control?*
- Yes
- No
What is the name of the parasite control?
How frequently do you administer parasite control?
Does Your Pet Receive Regular Dental Care?
If so, What (check all that apply)?
- Brush
- Rinse
- Chews
- H20 Additive
- Dental Diet
- Other
If Other, Please Describe.
I prefer any future lab results be delivered by
- Cell Phone
- Home Phone
- Work Phone
- Other Phone
- Email
Other Phone
Does Your Pet Have Any Vaccines Due (check all that apply)?
- DAPP
- Rabies
- Leptospirosis
- Bordetella
- H3N2+8
- RCP
- FELV
Medical Records that may pertain to your visit.
Drop files here or

Accepted file types: jpg, pdf, Max. file size: 128 MB, Max. files: 3.

Mon – Fri: 8a – 6p
Sat: 9p – 3p
Sun: CLOSED

Address:

11416 98th Ave NE
Kirkland, WA 98033

Email:

info@juanitabayvet.com

Phone:

(425) 823-8411

Hours:

Mon – Fri: 8a – 6p
Sat: 9p – 3p
Sun: CLOSED

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