Intake History Form | Kronenwetter Veterinary Care in Kronenwetter, WI

Client's Name(Required)

Phone(Required)

Patient's Name(Required)

What type of pet is the patient?(Required)

Dog

Cat

Reason(s) for your pet’s appointment?(Required)

Annual Wellness

Vaccinations

Lab Work

Concerns

Please list the concerns for your pet's appointment.(Required)

Is your pet experiencing any of the following? If yes, please elaborate below(Required)

Lumps

Lumps(Required)

New

Old

Both

Location(s)(Required)

Changes(Required)

Irritation?(Required)

Yes

Skin

Skin(Required)

Itching

Sores

Changes in color

Other

Please list "Other" skin condition(Required)

Does your pet have a history of allergies?(Required)

Yes

Unsure

Location(s)(Required)

Previous treatments(Required)

Outcomes(Required)

Current treatments(Required)

Limping

Limping(Required)

Non-weight-bearing

Partial weight-bearing

Intermittent

Cries out – very painful

Other

Please list "Other" limping symptoms(Required)

Which limb(s)?(Required)

How long?(Required)

Respiratory

Respiratory(Required)

Coughing

Sneezing

Lethargic?(Required)

Yes

If yes, how long has your pet been lethargic?(Required)

Discharge produced?(Required)

Yes

If yes, describe discharge?(Required)

Any known kennel cough exposure?(Required)

Yes

Unsure

If yes, when did you notice the cough(Required)

Are any other pets in your household symptomatic?(Required)

Yes

Digestion

Digestion(Required)

Vomiting

Diarrhea

If vomiting – describe contents(Required)

If diarrhea – describe contents(Required)

Last food/water intake(Required)

Did they eat their usual portion?(Required)

Yes

Lethargic(Required)

Yes

If yes, how long has your pet been lethargic?(Required)

Urinary

Urinary(Required)

Increased frequency

Decreased frequency

Straining

Blood

Vocalizing – painful

Describe frequency(Required)

Do they need go throughout the night?(Required)

Yes

Volume(Required)

Increased

Decreased

Are they having accidents in the home / outside of the litterbox?(Required)

Increased

Decreased

How many litterboxes do you have and where are they located?(Required)

Ears

Ears(Required)

Left

Right

Both

Does your pet have a history of allergies?(Required)

Yes

If yes, please explain history of allergies(Required)

Is your pet experiencing excessive ear scratching or head shaking?(Required)

Yes

Do you regularly clean or treat the ears?(Required)

Yes

If yes, what is the name of product and frequency?(Required)

*Please consult your veterinarian BEFORE applying a cleanser or medication to the ear(s) the day of an appointment.

Eyes

Eyes(Required)

Right

Left

Both

Squinting

Rubbing

Any known injury?(Required)

Color changes?(Required)

Yes

If yes, please describe eye color changes(Required)

Drainage?(Required)

Yes

If yes, please describe drainage(Required)

Patient Information

Is your pet due for vaccinations?(Required)

Yes

Past due dog vaccinations(Required)

Past due cat vaccinations(Required)

Is your pet due for lab work?(Required)

Yes

Select dog lab work(Required)

List "other" dog lab work requested(Required)

List cat lab work requested(Required)

*If unsure, please input “Unsure”

Any new or recent tick exposure?(Required)

Yes

Unsure

Is your pet due for an annual fecal parasite screening?(Required)

Yes

Unsure

*If yes – Please present a fresh (less than 12 hours old) sample for testing.

Is this pet new to your household?(Required)

Yes

When did they join your family?(Required)

Where did they come from?(Required)

Breeder

Rescue

Other

Please send us any previous medical records at your earliest convenience.

Describe your pet’s lifestyle. Select all that apply.(Required)

Pet's Brand of Food(Required)

Special Formulation(Required)

Amount Fed Daily(Required)

Treats(Required)

Any Recent Changes in Diet?(Required)

Is your pet on any medications or supplements?(Required)

Yes

Please specify the name, dose, and frequency.(Required)

Refills Needed?(Required)

Yes

Heartworm Prevention(Required)

Flea/Tick Prevention(Required)

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