Medical History Form

Today's Date *

Client's Name *

First

Last

Email *

Patient Name *

Species *

Dog
Cat
Other

If other, please specify *

Age/D.O.B. *

Gender *

Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unknown

Color *

Breed *

Appointment Date & Time *

Date

Time

What is the primary reason for this appointment? (please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility) *

Have you been in contact with anyone that has been diagnosed with COVID-19 in the past 10 days? Do you have any symptoms of COVID-19 (coughing, fever, sneezing, malaise)? *

If yes, please tell us more: *

Do you have pet insurance for this pet? *

Insurance carrier & policy #: *

Which flea and tick preventative is your pet taking?

Last Date Given

Which heartworm preventative is your pet taking?

Last Date Given

List all other medications and supplements your pet is currently taking (medication/supplement name, dose, frequency):

Do you need refills of any medications/supplements today? *

Medication Name *

Quantity *

Refill Location *

Gladstone Veterinary Clinic
Other

If other, please specify *

What are you feeding? *

Wet food only
Dry food only
Mixture of wet & dry food
People food
Raw diet
Home-cooked diet
Treats/other

Wet Food - Brand(s)/formulation(s) of pet food and amount/frequency

Dry Food - Brand(s)/formulation(s) of pet food and amount/frequency

Mixture of wet & dry food - Brand(s)/formulation(s) of pet food and amount/frequency

People Food - What ingredients do you feed? And amount/frequency

Raw Diet - Brand(s)/formulation(s) of pet food and amount/frequency

Home-cooked Diet - What ingredients do you feed? Amount/frequency? Who formulated this diet for you?

Treats/other - What treats or other food do you feed? Amount/Frequency?

Do you need refills of any prescription diets? *

If yes, list brand, formulation, amount *

How is your pet’s appetite? *

Normal
Increased
Decreased

Comments

How is your pet’s thirst level? *

Normal
Increased
Decreased

Comments

Has your pet had any nausea, vomiting or regurgitation? *

Please describe the color, consistency, frequency, duration

Is it possible your pet may have eaten/ingested:

Garbage
Compost
Mushrooms
Marijuana/Other Drugs
Toys or other objects
Human or veterinary medications (accidentally)

If Other drugs, please describe: *

How are your pet’s bowel movements? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration

Does your pet experience flatulence (gas)? *

Please describe frequency and any comments

How is your pet’s urination? *

Normal
Abnormal

Please describe the color, consistency, frequency, duration, any urinary accidents

Has your cat urinated or defecated somewhere in the house, other than in the litterbox in the past 3 months? *

How many cats are in your household? *

How many litterboxes do you have? *

How is your pet’s energy/activity level? *

Normal
Abnormal

Energy level has *

Increased
Decreased

Comments

Please check which, if any, your pet has experienced in the past 2 weeks

Coughing
Sneezing

Please explain frequency, duration, and description of cough *

Please explain frequency, duration, and description of sneezes *

Has your pet ever had a seizure? *

Please explain frequency, duration, and description of seizure(s) *

Approximate date of last seizure

Does your pet have any behavior issues? *

If yes, please describe: *

Do you provide any home dental care? *

Type/frequency?

What is/are your pet’s lifestyle/social risks (including pre-pandemic activities): *

None
Grooming
Boarding
Travel outside of the Portland metro area
Dog Park
Doggy Daycare
Obedience Training

Where? *

What is/are your pet’s lifestyle/social risks (including pre-pandemic activities): *

None
Grooming
Boarding
Travel outside of the Portland metro area
Indoor only
Indoor/outdoor
Outdoor only

Where? *

Has your pet been prescribed any anti-anxiety medications to help decrease fear, anxiety, or stress during vet visits? *

If yes, please list medication name(s)

Please pre-medicate your pet as directed prior to his/her vet visit.

Is there anything else you would like to discuss during your pet’s visit today? *

Please explain:

APPOINTMENT PROCEDURES:

I understand that access to the Paris Road Animal Hospital building is limited to employees and pet patients only at this time due to the COVID-19 pandemic. For everyone’s safety, I understand that I must wear a facemask at all times during any direct interactions with the Paris Road Animal Hospital team. *

I have read and understand

I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone. *

I have read and understand

Name

Your preferred Chalmette, LA veterinarian.

Name: Paris Road Animal Hospital
Address: 2510 Paris Road, Chalmette, KA, 70043, United States
Telephone: 504-277-1277
Price range: $

Our veterinary hospital is owned and run by Dr. Christopher Baudy, Dr. Alexandrea Baudy and Dr. Nicolas Rose who are all licensed, experienced veterinarians.

Contact

Phone: 504-277-1277
Email: parisroadah@gmail.com



Location

2510 Paris Road
Chalmette, Louisiana 70043
Click here for directions.



HOURS

Mon, Tue, Thur & Fri: 7:30am – 5:00pm
Wed: 8:00am – 2:00pm
Sat: 8:00am – 12:00pm
Sun: Closed

Visit our

Online Pharmacy

SHOP NOW

Get your pet's food and supplies delivered right to your front door!

Have a question?

Get in touch!

Name *

First

Last

Email *

Phone

How can we help you? *

Website

Ready to come see us?

We look forward to seeing you soon! Request your next appointment with us using our online request form.

BOOK NOW