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: _____________________________________________________________

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______________________________________________________________________

History :

Do you or your pet have specific needs when visiting our office? _______

If yes please describe:_______________________________________________________

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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.

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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):

__________________________________________________________________________

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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?

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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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