MEDICAL HISTORY: Emergencies

Medical History: Emergencies

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Contact Information
Your name

First NameLast Name
Your email
Optional: If you enter in your email, we can 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 (reason for visit) today?
describe the reason for your visit
Is the problem the result of a trauma?
e.g. hit by car, fall, N/A, etc.
When was your pet last normal?
Is your pet currently experiencing any of the following symptoms?
Difficulty breathing
Collapse
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
Coughing
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?
Sneezing
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?
Is there any nasal discharge? Is it bloody?
Vomiting
When did it start?
How often does it occur?
Has the vomiting gotten better, worse, the same?
Is the dog actively vomiting (heaving) or is it more like an urp?
Diarrhea
When did it start?
How often does it occur?
Has the diarrhea gotten better, worse, the same?
Is there an urgency to go?
Is there blood in the diarrhea?
Is the diarrhea black like tar?
Lameness
Which leg?
When did it start?
Has it gotten worse?
Pain
Is your pet drinking normally?
Are they drinking more or less?
Is your pet urinating normally?
Are they urinating more or less?
Is there blood in the urine?
Is your pet eating normally?
Are they eating more, less or not at all?
How long have they not been eating?
What is your pet's normal diet?
kibble, prescription, raw, other
Does your pet have any known 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'
Please list any medications to which your pet has an allergy or has had a bad reaction:.
Please list any allergies your pet has:
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us during your time of emergency.
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
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Contact Information

Is your pet currently experiencing any of the following symptoms?