Patient History Form

Please fill out this form as completely as possible before your visit.

Name *

First

Last

Email *

Phone Number *

Are you currently a client of Knox Pet Clinic? *

Pet's Name *

Pet's Species *

Pet's Breed

Pet's Age

Where does your pet spend the majority of their time? *

Inside
Outside
Both

Has there been any change in diet? *

Is your pet currently taking any parasite prevention? (flea, tick, heartworm) *

Is your pet currently taking any medications/supplements? *

What is the reason for your pet’s upcoming visit? *

Does your pet have any preexisting medical conditions we should know about? *

Has your pet traveled recently? *

Any other pets in the household? *

Is your pet in need of a recheck from a previous exam? *

Has your pet been coughing? *

Has your pet been experiencing eye issues? *

Has your pet been experiencing ear issues? *

Have you noticed any lumps? *

Any behavioral concerns? *

Does your pet have a history of seizures? *

Does your pet have a history of skin issues? *

Has your pet been having any issues urinating? *

Has your pet been vomiting? *

Has your pet been experiencing diarrhea? *

Does your pet have issues bearing weight on all 4 limbs? *

Have you noticed any issues with your pets mouth, teeth or gums? *

Have you noticed any issues with your pets nose or throat? *

Has there been a change in sleeping behavior? *

Please attach any photos concerning the reason for your visit.

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

We have two awesome locations for your convenience!

Galesburg

Knox Pet Clinic

658 W Main St
Galesburg, IL 61401
309-343-6156

Hours

Mon-Fri: 7:30am - 5:00pm
Sat: 8:00am - 12:00pm
Sun: Closed

Knoxville

Knox Pet Clinic - Knoxville

105 North Public Square

Knoxville, IL 61448

309-289-6697

Hours

Mon: 8:00am - 4:00pm
Tues: 8:00am - 4:00pm
Thurs:8:00am - 4:00pm

If you are experiencing an after-hours emergency, please call 309-342-1759