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Veterinarians London, Ontario | Main Street Veterinary Services

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2360 Main Street, PO Box 211
London, ON
N6P 1P9

Ph: (519) 203-2000

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History intake Form

Home » History intake Form

New Client History Intake Form

History Intake Form
Your Name*
First Last
Pet's Name*
First
Email*
Enter Email Confirm Email
Phone - Best Contact #
Please describe the primary complaint with your pet that prompted you to contact us. List any and all symptoms that you would like addressed with this visit.*
• What makes these symptoms better or worse? (ex. Time of year, time of day, stress in the home, foods etc.)
• Vaccine history: when, how often and for what?
Diet currently on and diets that have been tried.
• Any known or suspect food intolerances and the reaction(s) that they cause.
List medications and/or supplements that your pet is currently taking including frequency and dose and describe what has been his/her response
Previous medications and/or supplements and response.
• Past medical history, treatments that were used and the response to treatment.
• Describe your pet’s temperament both at home and about town.
• Any personality quirks? Describe his/her behaviour with others in the house and with strangers. Describe how your pet interacts with other animals.
• How well does he/she sleep and where does he/she sleep? Does he/she get up in the night to go to the bathroom? Does your pet prefer soft or hard surfaces? Does he/she prefer cold or warm surfaces to lie on? Do these preferences change throughout the day?
Describe the daily routine of your pet
Gastrointestinal Issues
Please check all that apply
- vomiting
- diarrhea
- gas
- bloating
- constipation
• Describe the appearance of any vomiting or diarrhea. • Describe any patterns associated with these symptoms. • How is your pet’s appetite and thirst and when does your pet eat during the day?
Respiratory
Please Check all that apply
- coughing
- sneezing
- shortness of breath
- snoring
- excessive panting
• Exercise tolerance and activity level, what does your pet do for exercise in the day and how does he behave afterwards?
Musculoskeletal
Please check all that apply
- soreness
- lameness
- stiffness
- difficulty getting up or down
Please describe places where your pet does not like to be touched or groomed
Skin
• Description of hair/coat, rashes, itching, discharges, greasiness, dryness, dander.
• Urinary System
Please check all that apply
- house soiling
- urinary incontinence
- episodes of cystitis
- needs to go the bathroom during the night
Litterbox or bathroom habits
• Head, Ears, Eyes, Nose and Throat
Head, Ears, Eyes, Nose and Throat
- Changes in vision or hearing
- drools or is a messy eater or drinker
- oral health concerns (bad breath, tartar, red gums)
Description for any of the above mentioned check marks
Name
This field is for validation purposes and should be left unchanged.

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Location Hours

Monday	9:00am – 6:00pm
Tuesday	9:00am – 5:00pm
Wednesday	9:00am – 8:00pm
Thursday	9:00am – 5:00pm
Friday	9:00am – 6:00pm
Saturday	Closed
Sunday	Closed

Location

Main Street Veterinary Services
2360 Main Street, PO Box 211
London, Ontario, N6P 1P9

Pet Services

Pet Health Checker
myPetED
Homeopathic Medicine
Chiropractic Services
Acupuncture
Flea Control
Dermatology (Skin)

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