Patient History Form Please fill out this form as completely as possible before your visit. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Are you currently a client of Knox Pet Clinic? *NoYesPet's Name *Pet's Species *Pet's BreedPet's AgeWhere does your pet spend the majority of their time? *InsideOutsideBothHas there been any change in diet? *NoYesIf yes, what has changed, what is being fed, how much, frequencyIs your pet currently taking any parasite prevention? (flea, tick, heartworm) *NoYesAre you interested in purchasing any today? *NoYesIf yes, what prevention is your pet currently takingIs your pet currently taking any medications/supplements? *NoYesIf yes, please list all medications and supplements your pet is on and how frequently.What is the reason for your pet’s upcoming visit? *Does your pet have any preexisting medical conditions we should know about? *NoYesIf yes, please specify.Has your pet traveled recently? *NoYesIf yes, please specify.Any other pets in the household? *NoYesIf yes, please specify.Is your pet in need of a recheck from a previous exam? *NoYesIs the initial problem better, worse or the same?Are you able to give medication as prescribed?Are you finished with prescribed medication?NoYesAny change in appetite or drinking habits while on medication?Any vomiting, diarrhea, or constipation while on medication?Has your pet been coughing? *NoYesIs it a productive cough? If so, what does your pet cough up?Has your pet been boarded or around other pets recently? Is there a day/time the cough is more prominent?Has your pet been experiencing eye issues? *NoYesIs there any pain/squinting?NoYesIs your pet rubbing eyes a lot?NoYesAre any other pets/people in the household experiencing similar symptoms?NoYesHas there been any known trauma to the eye?NoYesIf yes, please explainHave you tried any medications at home already?NoYesIf yes, please list medications and frequency.Has your pet been experiencing ear issues? *NoYesAre the ears painful?NoYesDo you clean ears on a regular basis?NoYesIf yes, what product do you use?Is pet scratching/shaking head a lot?NoYesHave you tried any medications at home?NoYesIf yes, please list medications and frequency. Does your pet have a recent history of swimming, bathing or a moist environment?NoYesIf yes, please explainHave you noticed any lumps? *NoYesPlease listAny behavioral concerns? *NoYesPlease listDoes your pet have a history of seizures? *NoYesHow long has your pet had seizures?How far apart are the seizures?Are there any obvious triggers for the seizures?How long do the seizures last?Are the seizures getting progressively worse?Does your pet have cluster seizures? (seizures close together)Does your pet urinate, defecate, or vomit during or after the seizure?Does your pet have a history of skin issues? *NoYesIs your pet scratching?Is your pet chewing/licking any specific places of the body?How long has the skin issues been going on for?Have you seen fleas or any other parasites on the pet?Have the lesions been spreading?Have you tried medication? If so please list and explain dose and frequencyHas your pet been having any issues urinating? *NoYesIs your pet straining? (trying to urinate with no success)What is the color of your pets urine and frequencyAre your pets bathroom habits different?Does your pet still have control over the bladder?Has your pet been vomiting? *NoYesIs there a particular day/night that the pet vomits?Have you opened a new bag of food?Have you given your pet rawhides, bones, or new treats?What is the vomit consisting of? (phlegm, bile, food etc.)What color and consistency is the vomit? How long after eating does the pet vomit?Does your pet eat quickly?Does your pet have a history of eating garbage, table scraps, toys, or strings?Have you tried a bland diet?Have you tried any medication? If yes, what medication and what is the frequency?Has your pet been experiencing diarrhea? *NoYesPlease describe the diarrhea (bloody, mucousy, watery, amount, color, consistency)What are your normal feedings?Any recent change to your pet’s diet?Did you recently open a new bag of food?Does your pet have a history of eating garbage, table scraps, toys, or strings?Have you tried a bland diet?Have you tried any medication? If yes, what medication and what is the frequency?Have you given your pet rawhides, bones, or new treats?Has your pet gone through any stress recently? (boarding, change in environment) Does your pet have issues bearing weight on all 4 limbs? *NoYesWhich legs are affected? Is it shifting leg lameness?Has it been acute or rapid onset?Have you noticed any swelling?Have you noticed any blood?Have you noticed any issues with your pets mouth, teeth or gums? *NoYesIs there an odor?Do they favor one side of the mouth when eating?Is there a history of trauma?Does your pet have excessive drooling?Does your pet paw at its mouth?Change in your pets food preferences? (hard, soft, semi-soft)Do you have a dental plan you follow?Have you noticed any issues with your pets nose or throat? *NoYesHas there been any difficulty swallowing?Any sneezing, nasal discharge, or bleeding?If discharge is present, is it one or both nostrils?LeftRightBothIs there a day/ time when symptoms are worse?Have you tried any medication to help with symptoms?Has there been a change in sleeping behavior? *NoYesIf Yes, please explain.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. EmailSubmit We have two awesome locations for your convenience! Galesburg Knox Pet Clinic658 W Main St Galesburg, IL 61401 309-343-6156 HoursMon-Fri: 7:30am - 5:00pm Sat: 8:00am - 12:00pm Sun: Closed Knoxville Knox Pet Clinic - Knoxville105 North Public Square Knoxville, IL 61448 309-289-6697 HoursMon: 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