Companion Animal Hospital, LLC

3720 US Highway 431 North
Phenix City, AL 36867

(334)297-2316

www.companionanimalphenixcity.com

Pet Health History Form

Complete a form for each pet

Name (required)

First Name (required)	Last Name (required)

Pet's Name (required)

First Name (required)	Last Name (required)

Sex (required)

Male
Female

Neutered/Spayed (required)

Yes
No

If yes, what age?

Breed (required)

Age (required)

Color

What age was pet obtained?

From where was the pet obtained?

Breeder
Pet Shop
Shelter
Other

Describe your pet's diet (required)

Any prior illness or surgery that we should know about?

List your pet's current medication(s), if any

Currently on a Heartworm prevention? (required)

Yes
No

If yes, what brand?

If yes, is it given year round?

Yes
No

Please list the last vaccines that were given (required)

Where/when were these vaccines given? (required)

Primary reason for your visit (required)

Please check any medical symptoms or problems you've noticed with your pet
Appetite Loss
Bad Breath
Behavioral Changes
Breathing Problems
Changes in Weight
Coughing
Depression
Diarrhea
Eye Disorders
Gagging
Gums Bleeding
House/Litter Box Training
Itching, Licking, Scratching
Limping
Loss of Balance
Mouth Sensitivity/Drooling
Scooting
Shaking Head
Skin/Coat Condition or Odor
Sneezing
Stiffness or Pain on Rising
Thirst
Urination Increase
Vomiting
Weakness

Please list any behavior concerns

Anything else you would like to share about your pet?

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