Helping Your Family Pets Since 1976 Needham Animal Hospital

Pre-Exam Patient Health Summary

This form is specifically for patients with existing appointments at Needham Animal Hospital.  Filling out this form WILL NOT create an appointment at Needham Animal Hospital.  We request that you fill out this exam summary electronically prior to your appointment. 
Thank you!

Needham Animal Hospital

  • Please enter your name.
  • Please enter your phone number.
    This isn't a valid phone number.
  • Please enter pet's name.
  • Please enter time
  • Please enter a message.

    (Please be as detailed as possible)

  • What is your pet’s energy level?*

    Please make a selection.
  • Has your pet had any coughing or sneezing*

    Please make a selection.
  • Has your pet had any vomiting? *

    Please make a selection.
  • Has your pet had any diarrhea?*

    Please make a selection.
  • Has your pet had any unusual scratching or licking? *

    Please make a selection.
  • Has your pet had any soreness or stiffness? *

    Please make a selection.

    (ie: limping, trouble jumping up, rising from laying down)

  • Has your pet had any behavior changes?*

    Please make a selection.
  • Does your pet have any lumps or bumps you are concerned about?*

    Please make a selection.
  • Describe your pet's thirst*

    Please make a selection.
  • Desribe your pet's appetite*

    Please make a selection.
  • Describe your pet’s urinations: (select all that apply)*

  • Is your pet allergic to any food or medications?*

    Please make a selection.
  • Has your pet every had an adverse reaction to a vaccine?*

    Please make a selection.
  • If your pet is a cat, does your cat go outdoors?*

    Please make a selection.
  • Are there any previous medical problems we should be aware of?*

    Please make a selection.
  • Please enter type of food.
  • Please enter how much and how often.
  • Do you take your pet to any of the following: (select all that apply)*

  • Is your pet exposed to any of the following?:(select all that apply)*

  • Do you travel with your pet?*

    Please make a selection.
  • Do you practice any home dental care for your pet?*

    Please make a selection.
  • Is your pet on flea prevention?*

    Please make a selection.
  • Is your pet on heartworm preventative?*

    Please make a selection.
  • Is your pet on any medications/supplements?*

    Please make a selection.
  • Do you need refills on your pet's medications?*

    Please make a selection.