Patient Medical History Your pet's Full Name (including last name)*Breed:*Age:*Is he/she spayed or neutered?* Yes No Unsure What is the reason for your visit?*Please list any medications your pet is taking, including supplements:Include dose and frequency.Is your pet on flea/tick/heartwork preventatives, and which type(s)?*Please list any significant medical history for your pet, such as surgery, illness, chronic conditions, injuries, etc.What does your pet eat, how much, and how often?*Please also include any regularly given treats or additional food, such as table scraps.How would you describe your pet's appetite and energy level?*Is your pet currently experiencing any of the following symptoms?* Coughing Sneezing Vomiting Diarrhea Pain/Limping Lumps and Bumps Acting "Not Right" Lethargic Not going to the bathroom Straining to go to the bathroom Not eating Not drinking Drinking too much Bleeding or other discharge Bad smell None of the above Select all that apply. If any of these symptoms indicate a potential contagious disease, we will contact you regarding precautions for your appointment.If so, please add as much detail as you can about the symptom(s):Any additional concerns or information you'd like us to know?If your pet has been seen by another veterinarian, which one?We may need to contact your other veterinarian for vaccine information or other relevant medical history.Is your pet fearful or aggressive at the vet?* No Yes, Fearful Yes, Aggressive I am not sure. We are Low Stress Handling certified and tailor every exam to the patient's needs.Are you or any member of your household experiencing symptoms of a contagious illness?* Yes No This includes coughing, sneezing, fever, etc. We will take precautions to protect our staff and other clients.
