Home » Forms » Medical History & Current Concerns

Medical History & Current Concerns

"*" indicates required fields

Date*

Owner's First Name*

Owner's Last Name*

Pet's Name*

Best Phone Number to Contact You*

Best Email to Contact You*

Please have this form completed before coming to the hospital. This will help during the check in process, please include if you need a refill of medications or any questions that you may have for the doctor.

Briefly describe the reasons your pet is here for an exam, such as ear infection, sick or limping. Please answer all questions below regardless of why your pet is here.*

Has your pet had any coughing?*

Yes

No

Has your pet had any sneezing?*

Yes

No

Does your pet have any nasal discharge?*

Yes

No

If yes, what color and which nostril(s)?*

Has your pet been vomiting?*

Yes

No

If your pet has been vomiting, when was the last time and describe the vomit?*

Has your pet had diarrhea?*

Yes

No

Does your pet's stool look normal in color? Is it black or bloody?*

Yes

Black

Bloody

Has your pet been drinking more?*

Yes

No

Has your pet been urinating more?*

Yes

No

Have you seen your pet's urine?*

Yes

No

If so, what was the color and amount?*

Has your pet's appetite changed?*

Yes

No

If so, please describe how*

When was the last time you saw a bowel movement and what did it look like?*

Any change in diet?*

Yes

No

If so, when and what did you change?*

Is your pet lethargic?*

Yes

No

If so, how long?*

Is your pet here because it is limping?*

Yes

No

If so, which leg and how long?*

Please list all medications your pet is on and when they were last given*

Has your pet cried out?*

Yes

No

If so, what was your pet doing when this occurred?*

Does your pet have a problem with one or both of its eyes?*

Yes

No

If so, which eye? Describe any drainage or symptoms.*

Does your pet have a problem with one or both of its ears?*

Yes

No

If so, which ear? Describe any discharge or symptoms.*

Do you have a concern with your pet's teeth?*

Yes

No

If yes, please describe*

Are there any new lumps or bumps you have found?*

Yes

No

If so, where are they and how long have they been present?*

Please use this area to write any information that you feel would be helpful in treating your pet today. We will do our best to have your pet seen and communicate a plan as quickly as possible.

Signature*

Comments

This field is for validation purposes and should be left unchanged.