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Pet Health History Questionnaire Form Coulter Animal Hospital in Amarillo, TX

Save time during your next appointment! Complete your required forms online from any device before your visit.

Pet Health History Questionnaire Form

Save time during your next appointment! Complete our hospital’s Pet Health History Questionnaire Form online from any device before your visit.

Name *

First

Last

Pet's Name *

Phone

Phone Type

Phone Number *

I consent to receive SMS text messages from Coulter Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Additional Phone

Phone Type

Emergency Contact *

Emergency Contact Phone

Phone Type

Emergency Contact *

Current Medications your pet takes (daily or monthly): (required) *

Any Existing Medical History we need to know about your pet: (required) *

Primary Reason for Visit (required) *

Eating normally? *

If no, when did it start? *

Drinking normally? *

If no, when did it start? *

Lethargy *

If yes, when did it start? *

How often does it occur? *

Diarrhea *

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)? *

Vomiting *

If yes, when did it start? *

How often does it occur? *

Coughing *

If yes, when did it start? *

How often does it occur? *

Sneezing *

If yes, when did it start? *

How often does it occur? *

Does your pet go to the groomer, dog park, or boarding facility? *

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

Ear Problems *

Which Ear(s) *

Right Ear
Left Ear
Both Ears

If yes, when did it start? *

How often does it occur? *

Scooting *

If yes, when did it start? *

How often does it occur? *

Licking: *

If yes, when did it start? *

How often does it occur? *

Location on body *

Itching *

If yes, when did it start? *

What is the itch level? (1-10) *

Location on Body *

Limping *

Which leg? *

Right Front
Left Front
Right Rear
Left Rear

If yes, when did it start? *

Stiffness? *

If yes, when did it start? *

Location on Body *

Lumps, bumps, or wounds *

If yes, when did you notice? *

Location on body *

Changes in activity level? *

If yes, when did it start? *

Tremors/shaking? *

If yes, when did it start? *

How often does it occur? *

Excessive panting or labored breathing? *

If yes, when did it start? *

How often does it occur? *

Any change in diet or lifestyle? *

If yes, what changed? *

Is your pet allergic to any medications? *

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) *

Date

Name

Ready To Book An Appointment?

We are a full-service veterinary clinic dedicated to providing the best care for your dog or cat. We are pleased to offer our compassionate veterinary care to the animals in Amarillo, TX and the surrounding areas. Book an appointment for your pet.

Book Appointment

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Location

5200 Coulter St.
Amarillo, TX 79119

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Contact Information

Phone: 806-353-6673
Email: coulterah@gmail.com

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Hours

Mon: 7:30 am – 6:00 pm
Tue: 7:30 am – 6:00 pm
Wed: 7:30 am – 6:00 pm
Thu: 7:30 am – 6:00 pm
Fri: 7:30 am – 6:00 pm
Sat: 8:00 am – 12:00 pm
Sun: Closed

Have A Question?

Get in touch! Complete our online form and a member of our team will be in touch with you shortly.

Name *

First

Last

Email *

Phone

I consent to receive SMS text messages from Coulter Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

How can we help you? *

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