618-750-PETS(7387)
hello@villagevetpet.com
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Patient History Form

Thank you for choosing Village Veterinary Hospital.
Please fill out the form as completely as possible.

Patient History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Pet's Name

Client Name *

Date of your Appointment

Phone *

Email *

Reason for Visit

Has your pet been examined elsewhere for the same condition?

Yes
No

When did the issue first begin?

Is the issue:

Improving
Continuing (stable or unchanging)
Worsening

Has your pet had any of the following issues (check all that apply)?

Coughing
Sneezing
Vomiting
Diarrhea
None of the above

Has your pet had any of the following (check all that apply)?

New lumps or bumps
Behavior changes
Changes in mobility
None of the above

My pet’s appetite is:

Normal
Increased
Decreased

My pet’s thirst level is:

Normal
Increased
Decreased

My pet’s activity level is:

Normal
Increased
Decreased

Has your pet’s urination/defecation habits changed?

Yes
No

Current Diet

Amount & Frequency of Feeding

What medication(s) and/or dietary supplements is your pet currently taking?

Is your pet allergic to any food or medications?

Yes
No

Has your pets diet changed in the last 6 months?

Yes
No
Unsure

Is your pet:

Indoor only
Mostly indoor but rarely goes outdoors
Indoor/outdoor
Outdoor only
Outdoor during the day/inside at night
Other

If other, please specify

Does your pet have any known health concerns or chronic conditions?

Do you have any concerns that you would like to bring to the doctors attention or areas that you would like the doctor to pay special attention to while your pet is with us?

Do you have pictures or videos that would help us with your pet's exam?

Click or drag a file to this area to upload.

Is there anything else you would like to discuss at your appointment?

Ready to Visit?

We Know Pets Are Family

Let us show you how we can make veterinary visits less stressful, more engaging for the entire family, and fear-free. We are here to help with your pet throughout your journey together.

Schedule Appointment

Questions?

Get in touch! We look forward to hearing from you.

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Location

2533A Vandalia St.
Suite B
Collinsville, IL 62234

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Contact Information

Email: hello@villagevetpet.com
Phone: 618-750-PETS (7387)

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Hours

Monday – Friday: 8:30 am – 5:30 pm

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We Proudly Serve the Pets of the Collinsville, IL Area, and Surrounding Towns in the MetroEast Area

Maryville, IL
Glen Carbon, IL
Edwardsville, IL
Troy, IL
Alton, IL
Godfrey, IL

O'Fallon, IL
Marine, IL
St. Jacob, IL
Highland, IL
MetroEast St. Louis

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