Glenway Animal Hospital - Veterinarians - Cincinnati ...
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Glenway Animal Hospital Pre-Appointment History Form
6272 Glenway Avenue
Cincinnati, Ohio 45211 Pet’s Name_____________________________
(513) 662-0224
Your Name _____________________________
Type of appointment: (Please circle one): Wellness Recheck Sick
Concerns: _____________________________________________________________
______________________________________________________________________
______________________________________________________________________
History :
Do you or your pet have specific needs when visiting our office? _______
If yes please describe:_______________________________________________________
___________________________________________________________________________
List all medications your pet takes with the information on how much you give (pill number and dose) and how often given. This will be for all over the counter, prescription, Heartworm Prevention, Flea prevention and tick prevention.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Which medications do you need refilled. ____________________________________
Has your pet had any adverse reactions to vaccinations or medications? Yes___ No____
What is the usual diet? (Please include brand and type, wet vs. dry and amount daily):
__________________________________________________________________________
_________________________________________________________________________
Does your pet go to public places or is it around other dogs? Yes____ No____
Please specify: boarding/kennel _____ groomer_____ Dog Park _____ Daycare_______
What type of dental care do you do at home? __________________________________
How often? ______________________________________________________________
Do you currently have a health insurance policy for your pet? If so, which company?
__________________________________________________________________________
__________________________________________________________________________
In addition to above issues I have questions about the following . If you wish to have an estimate prepared for any of the following, please put a star by the check mark. We are always happy to provide estimates for services before they are done. Please feel free to ask for one at any time.
______ Behavior ______ Obedience Classes _____ Diet/weight control ____ Dental Care
_______ Dental Cleaning / Prophylaxis _______ Spay / Neuter_____ Flea and Tick Control
______ Heartworm Disease Prevention ______ Gastrointestinal parasites
______ Grooming / Boarding _______ In home pet care services
Medical Conditions:
Please circle and/or list all concerns you would like the veterinarian to be aware
of and address at this visit.
Allergies Watery Eyes Coughing Sneezing Itching (where?)
Scooting Diarrhea Constipation Straining (to urinate or defecate?)
Inappropriate urination or defecation Leaking urine
Limping Ear infection Skin lesions Broken tooth
Broken nail Bad breath Seizures Panting Exercise intolerance
Difficulty getting up Swollen abdomen Storm &/or firework phobias
Lump(s) - please be ready to identify location of lesions
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