Medical History

Your Name:

Your Pet's Name:

Appointment Date:

Phone # to contact you during the appt:

Email to send your invoice to:

Reason for visit:

Current Heartworm & Flea Preventative:

If Other, Please list:

Any lapse in prevention:

Current medications/supplements:

Current diet:

Will your pet be fasted

If yes, for how long? (fasting is recommended when labwork is needed; ideally for 12 hrs.)

Changes in appetite:

Changes in water consumption:

Any change in urination:

Any Recent (coughing/sneezing/vomiting/diarrhea/discharge):

Any change in behavior:

If Yes, please describe:

Any lumps or swelling noticed:

If Yes, please describe:

Any recent travel or future travel plans:

If Yes, please describe:

Possible exposure to other dogs (dogs only):

Possible exposure to other cats (cats only):

Last Heat Cycle (for intact females)

Any additional significant information the doctor should know, significant previous medical history or additional issues you would like addressed during the visit:

Any medication refills requested:

Patient Medical History for Office Visits