Oral & Dental History Step 1 of 2 50% Today's Date Date Format: MM slash DD slash YYYY Client InformationName* First Last Email* Spouse/Other Authorized Contact Name First Last Spouse Phone NumberAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work Ph.Cell Ph.*How did you become aware of our practice?DVM ReferralInternetPersonal RecommendationName of DVM ReferralName of Personal Recommendation Patient InformationPatient Name* First BreedColorDate of Birth Date Format: MM slash DD slash YYYY or Estimated AgeIn order to assess your pet’s oral health, we would appreciate if you could provide us with some important information by answering the following questions: SexFemaleMaleSpayed/Neutered?YesNoVaccination history (including rabies) Up to date:YesNoAny previous serious illnesses or surgeriesYesNoAny known allergiesYesNoList any previous serious illnesses or surgeries:List any known allergies:Any medications/supplements your pet is takingYesNoAny previous dental treatmentYesNoList all medications/supplements your pet is currently taking (ex: Fish Oil):List any previous dental treatment:Approximately how long have you had your pet?How did you acquire him/her?What is your pet’s normal diet?Do you provide any at-home oral care for your pet?YesNoIf so, what and how often?Please describe the reason for your visit today and when you first became aware of this concern.1. Decreased appetite:YesNo2. Abnormal chewing:YesNo3. Halitosis (bad breath):YesNo4. Excessive salivation/drooling:YesNo5. Broken tooth:YesNo6. Oral growth:YesNo7. Oral pain or sensitivity:YesNoAre there any other symptoms of oral problems or dysfunction?Does your pet have a known heart murmur or other cardiovascular problem?:YesNoDoes your pet have any other health problems?YesNoList these: This iframe contains the logic required to handle Ajax powered Gravity Forms.
