The AMC Diabetes History Form

If you do not yet have an appointment, please call the AMC at (212) 838-7053 to schedule one. Only fill out this form if you have an appointment scheduled with us.
After you have made your appointment and prior to your visit to The AMC, please fill out and submit the following information to us. Doing so will speed your visit, since we will already have your information and your pet’s information on file when you arrive. Fields marked with a red asterisk (*) are required.
Note: The AMC does not release personal information to any third parties.
Patient Information
     
*Client Name *Client Phone # Blue Card #
*Pet’s Name *Appointment Date
     
General Information
 
1. What kind of food does your pet eat?
Brand
Dry or Canned
Treats
2. How often do you feed your pet?
 
3. Have you noticed a change in your pet’s appetite recently?
Yes, please explain
No
4. Does your pet eat “human food”?
Yes
No
5. Has your pet’s weight changed recently?
Gain
Loss
 Unsure
Has not changed  		 
6. Have you noticed your pet urinating more than in the past?

Yes
No

7. Have you noticed your pet drinking more than in the past?
Yes (If so, approximately how much more?)
No
8. CATS ONLY - What type of litter do you use?

Wood Chip
Gravel/Scoopable
Newspaper
Crystals
Non-Absorbent Litter

9. Please list all prior therapies.
10. Did these therapies help?
Yes (If so, which therapies?)
No
11. Is your pet currently on insulin?
Yes (if so, what kind, how much & what frequency?)
No
12. Where do you inject the insulin? (Please indicate on the diagram below the approximate location(s) for injections by putting a check in one or more of the boxes shown)
 
   
         
 
 
     
   
     
     
   
     
     
         
 
13. Does your pet have diarrhea?
Yes
No
14. Have you noticed a change in your pet’s attitude or behavior recently?
Yes (If so, please explain)
No 
15. Has your pet’s energy level changed?
More than in the past
Less than in the past
Has not changed
  
16. Are you concerned about any other health issues regarding your pet?
Yes
No
(If yes, please explain.)

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