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Mon, Tues, Thurs, and Fri 7:30am – 6:00pm
Wed and Sat 8:00am-12:00pm
Sun closed

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History / Lifestyle Evaluation Form Town and Country Veterinary Hospital

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History / Lifestyle Evaluation 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.

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Consent

I understand that the purpose of this Patient History and Lifestyle Evaluation form is to recognize and assess risks in association with my pet — particularly with regard to animal-borne diseases that may affect me or other household members. Further, I understand that I need NOT complete this form, nor need I answer all the questions to remain a client of this veterinary practice. This information will become part of my pet’s medical record, will be treated as confidential, and will not be shared with any third parties. I hereby consent to the use of this form as described. *

I Accept

Your signature: *

Date *

Your name (printed): *

Your pet’s name: *

Age: *

Breed: *

Gender *

Male
Female

Neutered/Spayed? *

Geographical History

Where do you currently live? *

Where else has this pet lived? *

Do you vacation or travel with your pets *

If yes, where have you taken your pet? *

Household Information

Are there other pets in the family? *

If yes, what kind of pets? (Include all species): *

What family members live in the household with the pet?

Number of infants and children (include ages): *

Number of adults: *

Seniors: *

Are there any persons in the household who have an impaired immune system? (This might make these people susceptible to some diseases of animals.): *

Where does your pet sleep? (Be as specific as possible: Indoors or outdoors? Which room and location within the room? In a pet bed, which is located where?) *

Access to the Outdoors and Contact with Other Dogs and Cats

Is your pet primarily indoors or outdoors? *

When was your pet last outdoors? *

When outdoors, which of these describes your pet’s degree of freedom? *

Free to run and explore
Confined to an exercise pen
Confined to the yard
Only allowed outdoors on a leash

Is your pet exposed to dogs and cats, other than your own, at any of these locations? *

Back yard
Grooming facility
Boarding kennel
Puppy or kitten obedience or socialization class
Dog park
Dog or cat show
Obedience or agility trials

Vaccination History

When and where did your pet last receive vaccinations? *

Nutrition Information

What foods does your pet eat? *

Do you have total control over what your pet eats? *

Parasitology History

Do you ever see fleas on your pet? *

Do you use routine flea and tick control treatments? *

What specific products do you use? *

Do you ever find ticks on your pet? *

Does your pet ever receive a heartworm preventive medication? *

If so, when did your pet last receive this medication? *

When did your pet last have a heartworm test? *

Does your pet ever receive an internal parasite preventive medications? *

If so, when did your pet last receive this medication? *

When did your pet last have a fecal examination? *

Dental Care History

When did your pet last have a complete dental evaluation? *

When, if ever, did your pet last have a professional teeth cleaning? *

Do you brush your pet’s teeth routinely? *

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Have a question?

Get in touch! Complete our online form, and we will be in touch with you shortly. If you are dealing with an emergency during business hours, please call us directly at 931-967-3666.

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Location

44 AEDC Road
Winchester, TN 37398

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Location

44 AEDC Road
Winchester, TN 37398

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Contact Information

Phone: 931-967-3666
Email: townandcountryvetwinchester@gmail.com



Contact Information

Phone: 931-967-3666
Email: townandcountryvetwinchester@gmail.com

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Hours

Mon, Tues, Thurs, and Fri 7:30am – 6:00pm
Wed and Sat 8:00am – 12:00pm
Closed on Sundays

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Hours

Mon, Tues, Thurs, and Fri 7:30am – 5:00pm
Wed and Sat 8:00am – 12:00pm
Closed on Sundays

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How can we help you? *

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