530 Massachusetts Avenue, Boxborough, MA 01719
p: (978) 929-9200 • f: 978-929-9979
email: reception@veterinarydental.com

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Patient History Form (Dog)

Today's Date: Date of Birth:
Client Name: Patient Name:
Patient Sex: Male Neutered Male Female Spayed Female
Phone Number: Appointment Date:
Location for for routine care: Veterinarian's name:
Where did you find us? Primary Care Veterinarian Friend Internet While driving by Other
Why is your pet coming to see us?
Where did you get your pet from? Breeder Shelter Pet Store Other
If other, specify where:
How old was your pet when he/she came to live with you?
Is your dog a show dog? Is your dog a breeding dog? Is your dog an agility dog? Is your dog a service dog?
If your dog is none of the above, specify what:
What brand(s) of food do you feed your pet? What type of food is it? Canned Dry Both
What treats do you give your pet? How is your pet's appetite? Good Fair Poor
Does your pet have food, drug or environmental allergies/sensitivities? (If yes, please list them.)
Is your pet on any medications or supplements? Yes No
Please list all medications and supplements below.
Name: Strength: Frequency Given:
Name: Strength: Frequency Given:
Name: Strength: Frequency Given:
Has your pet been diagnosed with any of the following? (Please check all that apply.)
Kidney Disease Liver Disease Diabetes Heart Disease Heart Murmur Seizures Thyroid Disease
Breathing Difficulties Orthopedic Issues
Any other disease(s) or illness? Please describe:
Has your pet ever been hospitalized? Yes No      If yes, please explain:
When was your pet's last dental cleaning? Any previous extractions or oral surgery? Yes No
Has your pet been diagnosed with any of the following? (Please check all that apply.)
Bad breath Excessive drooling Pawing at mouth Painful when playing Painful when eating Grinding teeth
Any other symptoms? Please describe:
Do you brush your pet's teeth? Yes NoHow frequently?
How does your pet like it? Love Hate Tolerate
Please list all toys that you give your pet:
Please list all chews or other dental products that you give your pet:
Please list any other concerns or comments:
AAHA
Veterinary Dental Services, LLC
530 Massachusetts Avenue, Boxborough, MA 01719 · (978) 929-9200
FAX: 978-929-9979 Email: reception@veterinarydental.com

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