MEDICAL HISTORY: Oncology Initial

Medical History: Oncology Initial (Bellingham)

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Health Check
During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount.
Have you travelled to any countries outside the United States (including Canada) within the last 14 days?*

YesNo
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?*

YesNo
Did you have close contact with a person who travelled outside of the United States in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?*

YesNo
Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19?*

YesNo
Contact Information
Your name*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Phone number where you can be reached today
(XXX) XXX-XXXX
Your pet's name*
What is your primary concern today?*
Reason for visit
When did you first notice the problem?*
How has it progressed? Has it gotten significantly worse?*
Which tests have been performed?*

BiopsyCytologyNeither
Does your pet have any other major illnesses of which we should be aware? *
Is your pet currently experiencing any of the following symptoms?
Difficulty breathing?*

YesNo
Collapse?*

YesNo
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures?*

YesNo
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
Coughing?*

YesNo
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?

BetterWorseSame
Is your pet sneezing?*

YesNo
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?

BetterWorseSame
Is there nasal discharge?

YesNo
How would you characterize the discharge?
e.g. clear, green, bloody
Vomiting?*

YesNo
When did it start?
How often does it occur?
Has the vomiting gotten better, worse, the same?

BetterWorseSame
Is your pet actively vomiting (heaving) or is it more like an urp?
Diarrhea?*

YesNo
When did it start?
How often does it occur?
Has the diarrhea gotten better, worse, the same?

BetterWorseSame
Is there urgency to go?
Is there any blood in the diarrhea?
Is the diarrhea black like tar?
Lameness?*

YesNo
Which leg?
When did it start?
Has it gotten worse?
Do you think your pet is in pain?*

YesNo
Where is the pain?
Is your pet drinking normally?*

YesNo
Are they drinking more or less?

MoreLess
Is your pet urinating normally?*

YesNo
Are they urinating more or less?

MoreLess
Is there blood in the urine?
Is your pet eating normally?*

YesNo
Are they eating more, less or not at all?

MoreLessNot at all
How long have they not been eating?
What is your pet's normal diet?*
Does your pet have any food allergies?*
To what?
Please list any medications your pet is taking (including non-prescription and supplements). Include name, strength (mg), how often, for how long.*
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months' or N/A
Please list any medications to which your pet has had an allergy or has had a bad reaction?*
Or enter 'NA'
Please list any allergies:*
Or enter 'NA'
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for oncology treatment for your beloved pet:
e.g. I searched Google for 24 hour emergency vet; My vet recommends you for emergencies, etc
Feedback on this form? Send your thoughts to marketing@bbvsh.com
Is your pet currently taking any medications? If so, please list the name, dose, and frequency.*
What is your pet's current daily activity level?*
How have the home exercises been? Have you noticed any difficulties? *
Please rate your pet's level of comfort on their worst day. *

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1 is Worst, 10 is Best
Please rate your pet's level of comfort on their best day. *

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1 is Worst, 10 is Best
Should be Empty:

Medical History: Oncology Initial (Bellingham)

Health Check

Contact Information

Is your pet currently experiencing any of the following symptoms?