Crossgates Vet Medical History Form

1

Full Name* This field is required.

First Name

Last Name

2

Best Phone Number for Today's Appointment * This field is required.The Veterinarian and technician will use this number to communicate with you through the appointment

Area Code

Phone Number

3

Patient Species* This field is required.

Canine

Feline

4

Patients Sex* This field is required.

Male

Female

Male/Neutered

Female/Spayed

5

Primary Reason for Appointment /Concerns* This field is required.Please be as descriptive as possible- Include any chronic health conditions

6

Please list any Current Medications

7

Does your pet need medication refills?Please list below

8

Is the patient on Heartworm Prevention* This field is required.

Yes

No

I'm Not Sure

9

Please list Type/Brand of Pet food

10

How is your Pet's Appetite?

Normal

Decreased

11

Is your Pet Vomiting?

YESNO

12

Does your pet have Diarrhea?

YESNO

13

Is your pet Sneezing?

YESNO

14

Is your Pet coughing?

YESNO