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 are your goals for this visit?
 2. Is your pet under the care of a general practitioner?
No
Yes (If Yes, where?)
Name of Animal Hospital
Name of Veterinarian
Address of Hospital
Phone # of Hospital
 3. Has this Veterinarian referred you?
Yes
No
4. Would you like us to fax your pet’s medical records for them?
Yes
No
 
Questions About Your Pet
 
1. How long have you owned your pet?
0-6 months
6 months-1 year
 1-4 years
4-7 years 		7-10 years
10+ years 		 
2. Where did you get your pet? (Please be specific and check all those that apply.)

Animal Shelter
Pet Store
Private Home
Breeder
Other

3. Are there other pets in your home, including birds and reptiles?
Yes
No
4. Have you recently added other pets to your home?

Yes
No
If yes, Are these new additions up to date on their vaccines?
Yes
No

5. Which best describes your pet?
Indoor Only
Indoor Mostly/Outside Occasionally
Outdoor Only
Indoor/Outdoor
6. Is your pet exposed to animals, other than those in your home?
Yes
No
7. If your pet spends time outdoors, what type of environment is he/she exposed to? (Check all that apply)
Dog run
Backyard of field
Day care
 City streets
Groomer
Dog or cat show		 Wooded area
Boarding or cattery
Other
8. Has your pet ever lived or traveled outside of the Northeast United States?
Yes
If so, Where? When?
No
9. What does your pet eat?

Brand:  
Dry or Canned?  
Treats:  
10. How often does your pet get into the garbage or pick things up off the street?
Please state any significant event.
Explain
11. What other diets has your pet been on in the past?
Explain
 
12. What is your pet’s current vaccination status? (Check all that apply.)
Up to Date on:
DOGS: CATS:
Distemper
Parvo
Rabies
Lyme 		FeLV
FVR-CP
Rabies
13. Where does your pet urinate?
DOGS: CATS: What Type of Litter do you Use?
Backyard
Street
Inside Only
Other		 Wood Chips
Newspaper
Non-Absorbent Litter		 Gravel or Scoopable
Crystals
14. Is the elimination process observed?
Yes
No
15. Please list all prior therapies.
Explain:
  a. Did any of these help?
Yes
No
16. Does your pet have diarrhea?
No, (if no, skip to question 17)
Yes (if you answered yes)
  a. Please check any of the following that best describes your pet’s diarrhea.
 

Very watery
Contains blood
Frequently strains to defecate but only small amounts are produced at a time.
Loose but not too watery (Semi-formed)
Contains mucous
  b. How long has the diarrhea been occuring?
  c. Is the diarrhea...
 

Continuous (always present)
Episodic (present in cycles)
If episodic, how frequent are the episodes, and how long do they last
(i.e. once a week, 4-5 days every month, etc.)

  d. If you have other pets, do they have diarrhea also?
No
I do not have other pets
Yes (If yes, please describe.)
17. Does your pet Vomit?
No, (if no, skip to question 18)
Yes (if you answered yes)
  a. Please check any of the following that best describes your pet’s vomiting.
 

Generally occurs right after eating
Can occur any time day or night
I am not sure if the vomiting correlates with the time of eating
Occurs in the morning on an empty stomach
Occurs in association with diarrhea
  b. Please describe the vomitus?
Vomitus contains mostly undigested or partially digested food
Vomitus contains mostly phlegm
Vomitus contains mostly yellow fluid (bile)
  c. How long has your pet been vomiting?
  d. Is the vomiting...
 

Continuous (always present)
Episodic (present in cycles)
If episodis, how frequent are the episodes, and how long do they last
(i.e. once a week, 4-5 days every month, etc.)

  e. If you have other pets, do any of them vomit?
No
I do not have other pets
Yes (If yes, please describe.)
18. Does your pet have appetite problems?
No (skip to #19)
Yes, if you answered yes
  a. Does your pet
Completely refuse food?
Partially refuse food?
 

b. Is the refusal of food
Persistent (always present)
Episodic (present in cycles)
If episodic,
a. How frequent are the episodes?
b. How long do they last?
c. Are they associated with vomiting or diarrhea?

19. Has your pet lost weight?
No
Yes. If you answered yes:
What was your pet's maximum weight in the past?
Over what period of time is the weight loss noted?
20. Has your pet been treated with medication for his/her vomiting or diarrhea?
No
Yes. If you answered yes:
What medications were used?

Did the medication help, if so, which medications?
21. What medication is your pet currently taking?
22. Do any people in the household have gastrointestinal problems?
(i.e.: stomach ulcers, acute diarrhea, etc.)? If so please describe.
23. What diagnostic tests have been done on your pet?
Ultrasound
Fecal Testing
X-rays 		Giardia Testing
CBC/SMA
Fecal Cultures
Other tests not listed

Have you brought the results with you today?
Yes
No
24. Does your pet show any other signs of illness besides the gastrointestinal symptoms described on this form? Please check all that apply.
Coughing
Increased Urination
Inappropriate Urination/Defication
Sneezing
Seizures
Increase Drinking Habits
Collapse / Weakness
Other signs not listed