Taking the patient history every time you work with a patient, whether in the exam room or someone else in the hospital, it is vital that you take an accurate and thorough patient history. Whether this is in physical shorthand on a paper chart or typed into whatever program your hospital uses the importance of asking the correct questions of your client, recording them in the patient record and interpreting them to the veterinarian you're assisting is of utmost importance. There are a slew of questions you can ask of the pets owner depending on the reason the pet is presented that day. For now, we will go over the basic questions asked at every annual visit to gauge the general status and health of the pet over the last year. Please keep in mind that this set of questions will vary depending on the hospital Some may be omitted or others may be added based on how your hospital and doctors operate.

A helpful way to remember what questions to ask is by following the same flow that the veterinarian uses. To examine the pet from nose to tail in the veterinary field. The notes that make up a patient's medical history are called soap notes, which stands for subjective objective assessment plan.