Coulter Animal Hospital

5200 S. Coulter St
Amarillo, TX 79119

(806)353-6673

coulterah.com

Pet Health History Questionnaire

Name
First Name
Last Name
Pet's Name

Phone
Phone TypePhone Number
Additional Phone
Phone TypePhone Number
Emergency Contact

Emergency Contact Phone
Phone TypePhone Number
Primary Reason for Visit

Eating normally?
Yes
No


If no, when did it start?

Drinking normally?
Yes
No


If no, when did it start?

Lethargy
Yes
No


If yes, when did it start?

How often does it occur?

Diarrhea
Yes
No


If yes, when did it start?

How often does it occur?

Please check all that applies
Mucous seen
Blood seen
Parasite seen
Watery consistency
Loose consistency
Color change
Has your pet ingested anything different recently (i.e., people food, trash, toys, sticks, or etc)?
Yes
No


Vomiting
Yes
No


If yes, when did it start?

How often does it occur?

Coughing
Yes
No


If yes, when did it start?

How often does it occur?

Sneezing
Yes
No


If yes, when did it start?

How often does it occur?

Does your pet go to the groomer, dog park, or boarding facility?
Yes
No


If yes, when was his/her last visit and which facility?

Ear Problems
Yes
No


Which Ear(s)
Right Ear
Left Ear
Both Ears


If yes, when did it start?

How often does it occur?

Scooting
Yes
No


If yes, when did it start?

How often does it occur?

Licking:
Yes
No


If yes, when did it start?

How often does it occur?

Location on body

Itching
Yes
No


If yes, when did it start?

What is the itch level? (1-10)

Location on Body

Limping
Yes
No


Which leg?
Right Front
Left Front
Right Rear
Left Rear


If yes, when did it start?

Stiffness?
Yes
No


If yes, when did it start?

Location on Body

Lumps, bumps, or wounds
Yes
No


If yes, when did you notice?

Location on body

Changes in activity level?
Yes
No


If yes, when did it start?

Tremors/shaking?
Yes
No


If yes, when did it start?

How often does it occur?

Excessive panting or labored breathing?
Yes
No


If yes, when did it start?

How often does it occur?

Any change in diet or lifestyle?
Yes
No


If yes, what changed?

Is your pet allergic to any medications?
Yes
No


If yes, which medications?


After the completion of your pet's physical exam, we may have the need to perform blood tests ($91-$118), x-rays ($70-$175), or other non-invasive procedures. Do you authorize these, or would you prefer to be contacted first?

Yes, go ahead with whatever is necessary
No, please contact me first


I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet.
I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.
By typing your name, you are signing our form. (required)

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CLINIC HOURS:

Monday - Friday

7:30 AM - 6:00 PM

Saturday

8:00 AM - 11:00 AM

(No grooming available)

Sunday

C L O S E D

(No boarding drop-off/pick-up)

EMERGENCY AFTER-HOURS CALL 806-353-6673 AND FOLLOW THE RECORDED PROMPTS

*

Appointments Preferred

    Call for Walk-In Policy     


ePet Health is a private website that gives you secure online access to your pet's health information. We provide this ePet Health site free of charge to all clients who have an active email address on file.