201-391-9494 info@parkridgevet.com

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We offer same day appointments Monday through Saturday!

New Patient History Form

Save time during your next appointment! Complete your required form online from any device at any time before your visit.

New Patient History Form

Fill out your client form online to save time in the hospital!

Fields marked with an * are required

Name *

First

Last

Date

Email *

Pet's Name *

Age *

Any weight changes?

Weight gain
Weight loss
None

Severity

Mild
Moderate
Severe

When did problems begin?

Changes to appetite?

Increase
Decrease
None

Severity

Mild
Moderate
Severe

When did problems begin?

Vomiting?

No
Mild
Moderate
Severe

When did problems begin?

Diarrhea/ Soft Stool?

No
Mild
Moderate
Severe

When did problems begin?

Constipation/ Difficult defecation?

No
Mild
Moderate
Severe

When did problems begin?

Increased thirst/ urination?

No
Mild
Moderate
Severe

When did problems begin?

Any skin Problems?

Allergies
Chewing/ Licking
Dry skin/ coat

Severity

Mild
Moderate
Severe

When did problems begin?

Scratching ears/ Shaking head?

No
Mild
Moderate
Severe

When did problems begin?

Bad breath/ sore gums/ difficulty chewing?

No
Mild
Moderate
Severe

When did problems begin?

Fields marked with an * are required

House soiling/spraying?

No
Mild
Moderate
Severe

Explain

When did problems begin?

Decreased recognition of people, animals or previously learned commands

No
Mild
Moderate
Severe

Describe

When did problems begin?

Decreased affection/interaction with owner

No
Mild
Moderate
Severe

When did problems begin?

Decrease awareness (gets loss/confused)

No
Mild
Moderate
Severe

When did problems begin?

Chewing, licking, eating non food items

No
Mild
Moderate
Severe

Describe

When did problems begin?

Increased Irratibility/aggression

No
Mild
Moderate
Severe

When did problems begin?

Increased fear, anxiety

No
Mild
Moderate
Severe

When did problems begin?

Decreased tolerance for handling

No
Mild
Moderate
Severe

When did problems begin?

Decreased or selective hearing

No
Mild
Moderate
Severe

When did problems begin?

Fields marked with an * are required

Repetitive behaviors (e.g. pacing, overgrooming)

No
Mild
Moderate
Severe

Describe

When did problems begin?

Decreased grooming or self-care

No
Mild
Moderate
Severe

When did problems begin?

Muscle tremors/shaking/seizures

No
Mild
Moderate
Severe

When did problems begin?

Weakness/incoordintation

No
Mild
Moderate
Severe

When did problems begin?

Difficulty climbing stairs/stiffness

No
Mild
Moderate
Severe

When did problems begin?

Decreased activity - Sleeps more

No
Mild
Moderate
Severe

When did problems begin?

Excessive vocalization?

Day
Night

Severity

No
Mild
Moderate
Severe

When did problems begin?

Waking Owners at night

No
Mild
Moderate
Severe

When did problems begin?

Other problems/concerns *

Current medications *

Existing medical problems *

Current diet (brand) *

Amount fed (cups/cans) *

Frequency *

Name

Ready for a visit?

Park Ridge Animal Hospital proudly delivers lifelong care for your animals in Park Ridge, NJ and the surrounding areas. We look forward to seeing you and your pet soon!

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Where to Find Us

40 Park Ave #4
Park Ridge, NJ 07656



How to Reach Us

Phone: 201-391-9494

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Our Hours

Mon – Thurs: 7:30 am – 7:00 pm

Friday: 7:30 am – 5:00 pm

Saturday: 7:30 am – 2:00 pm

Sunday: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Website

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