Please fill out this form to the best of your ability prior to your appointment. Completing this form prior to your scheduled appointment gives our doctors more time to spend examining your pet, helping ensure that your pet receives top quality care.

Client Name *

First

Last

Pet Name *

At this time Lake Country is operating curbside. As a result, we will have you wait outside in your vehicle while your patient is taken inside the building for examination. Depending on the weather, the doctor will either come outside to discuss his/her findings or they will call you from inside the building to discuss. Please provide the number you wish us to use on the day of your appointment. Provide us with better history with your patient and give us more time during the appointment to physically examine your pet.

Phone *

Presenting Complaint

What clinical signs are you seeing in your pet?

If 'Other', please specify:

How long has this problem been going on for? *

Is the problem getting better, worse, or remaining the same? *

Better
Worse
Same

Has your pet experienced this problem in the past? *

Yes
No

Have you given any medications or supplements to your pet since the problem started? *

Yes
No

If yes, what medication or supplements have you given?

What, if any, previous diagnostics have been performed? *

If 'Other', please specify:

General History

Does your pet have any concurrent issues or previously diagnosed medical problems? *

Yes
No

If yes, please explain.

What is your pet's current diet? Please specify brand and amount *

Does your pet take parasite preventatives (i.e. heartworm, flea/tick prevention)?

Yes
No

If yes, please tell us what preventatives your pet is given and when the last dose was administered.

Please list any and all medications and supplements that your pet is being given below. Please include the dose your pet is given and how frequently they receive this medication. *

Has your pet ever had an adverse reaction to drugs, supplements, or vaccines? *

Yes
No

Has your pet demonstrated any recent behavioral changes? *

Yes
No
Other

If 'Other', please specify:

Has there been any change in your pet's environment or any recent travel? *

Yes
No

Is there any other history you feel would be relevant for the doctor? Please specify below.

Signature *

Today's Date *

Sick Physical Exam