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Patient Health Form

We’re excited to see you and your pet for their upcoming exam!

Patient Health Form - Healthy Paws Animal Hospital

Healthy Paws Animal Hospital

Patient Health Form · Pre-Visit Questionnaire

Welcome! Please select your visit type, complete the form, and click Submit Form. Your responses go directly to our team.

Step 1 · Select Your Visit Type

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Returning Client
Established Patient

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New Client
New Patient

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Returning Client
New Patient

Please select your visit type above to continue.

Patient & Owner Information

First Name *

Required.

Last Name *

Required.

Email *

Required.

Phone *

Required.

Patient Name (Pet) *

Required.

Species

Date

About Your Pet

How old was your pet when they joined your family? Where did you adopt? Did you see mom, dad, or littermates? *

Was your pet healthy at the time of adoption? *

Yes No Unknown

Other pets in household?

Children in household?

Yes No

Veterinary & Behavior History

Has your pet experienced anxiety, fear, or aggression at a vet or groomer? Ever needed to be muzzled? *

Yes No

Past major medical conditions, injuries, or surgeries *

Do you have previous veterinary records? Yes, I have previous records to share

Notes about your records

Previous veterinarian / clinic name

Previous vet phone

City / State

You can email records to service@hpah.org, bring them to your appointment, or we can request them from your previous vet on your behalf.

Medications & Adverse Reactions

Current medications, supplements, and/or preventatives *

Any adverse reactions to medications or vaccinations?

Yes No

Nutrition

What are you currently feeding your pet? Include brand, type, and measured amounts for food and treats. *

Social Media Permission

May we share your pet's image and story on social media or our website? Your personal information will never be shared.

Yes No thank you

Areas of Concern

Check all that apply

Vomiting Diarrhea Appetite Changes Water Consumption Urination / Litterbox Coughing / Sneezing Lameness / Stiffness / Pain Skin / Coat Changes Eye Concerns Ear Concerns Behavior Concerns No Concerns

Vomiting - Details

a. Most recent episode

Time

b. Frequency

Daily Weekly Monthly Intermittent

c. Contents

Food Water Yellow/green bile Unknown

d. Amount

TBSP 1/4 cup 1/2 cup 1 cup+

e. After car ride?

Yes No

Diarrhea - Details

a. Most recent episode

Time

b. Frequency

Daily Weekly Monthly Intermittent

c. Contains

Blood Mucous Formed but soft Liquid/watery

d. Amount

TBSP 1/4 cup 1/2 cup 1 cup+

e. Accidents in house?

Yes No

f. Straining?

Yes No

Appetite Changes - Details

Select all that apply

Increased appetite Decreased appetite Weight gain Weight loss

Water Consumption - Details

Change noted

Increased Decreased

Urination / Litterbox - Details

Select all that apply

Increased Decreased Straining Accidents in house Blood in urine

Respiratory - Details

Please describe

Lameness / Stiffness / Pain - Details

Symptoms

Limping Stiff Reluctant to jump/climb Painful when touched Slow to rise Slipping on floors Recent injury

Onset

Sudden Gradual

Limb/area affected

Front Rear Left Right

Duration

Skin / Coat Changes - Details

Select all that apply

Itching/licking/scratching Hair loss Redness/rash Bumps/masses Odor

Eye Concerns - Details

Which eye(s)

Left Right Both

Symptoms

Squinting Rubbing Redness Discharge Vision changes Cloudiness

Ear Concerns - Details

Which ear(s)

Left Right Both

Symptoms

Head shaking/scratching Odor Discharge Redness Painful

Behavior Concerns - Details

Select all that apply

Anxious Pacing/restless Aggressive Noise/storm sensitivity Car anxiety Separation issues

Other concerns or questions

Medications & Preventives

Current medications / supplements / preventatives

Refills needed

Nutrition

Current food (brand / type / flavor)

Amount & frequency

Additional Notes

Seen by another vet since last visit?

Yes No

Yes, I have previous records to share

Notes about your records

Veterinarian / clinic name

Phone

City / State

You can email records to service@hpah.org, bring them to your appointment, or we can request them on your behalf.

Anything else to share

Click the button below to send your form directly to our team.
Someone will review it before your appointment.

Ready to Visit?

We proudly serve the clients of Village of Lakewood, Bull Valley, Crystal Lake, Algonquin, Woodstock, McHenry, Cary, Lake in the Hills, Huntley, and beyond. We look forward to helping you and your pet! If you would like to schedule an appointment, please click the button below.

Book Appointment

Contact Us

Please complete the form below, and a member of our team will get back to you as quickly as possible. If your pet needs immediate treatment and it’s during normal business hours, please contact the office at (815) 322-5400.

Name *

First

Last

Email *

Phone

How can we help you? *

Message

We’re Here to Help

Get in touch! A member of our team will reach out shortly.

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Location

4581 Princeton Lane #101
Lake in the Hills, IL 60156

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Contact Information

Email: service@hpah.org

Call or Text: (815) 322-5400

Fax: 815-322-5401

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Hours

Monday & Tuesday: 7:00 am – 6:00 pm

Wednesday: 8:00 am – 6:00 pm

Thursday: 10:00 am – 6:00 pm

Friday: 7:00 am – 5:00 pm

Saturday & Sunday: Closed

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