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 Name
Last 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
*
Yes
No
Collapse
*
Yes
No
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures
*
Yes
No
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
Coughing
*
Yes
No
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?
Better
Worse
Same
Sneezing
*
Yes
No
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?
Better
Worse
Same
Is there any nasal discharge? Is it bloody?
Vomiting
*
Yes
No
When did it start?
How often does it occur?
Has the vomiting gotten better, worse, the same?
Better
Worse
Same
Is the dog actively vomiting (heaving) or is it more like an urp?
Diarrhea
*
Yes
No
When did it start?
How often does it occur?
Has the diarrhea gotten better, worse, the same?
Better
Worse
Same
Is there an urgency to go?
Is there blood in the diarrhea?
Is the diarrhea black like tar?
Lameness
*
Yes
No
Which leg?
When did it start?
Has it gotten worse?
Pain
*
Yes
No
Is your pet drinking normally?
*
Yes
No
Are they drinking more or less?
More
Less
Is your pet urinating normally?
*
Yes
No
Are they urinating more or less?
More
Less
Is there blood in the urine?
Is your pet eating normally?
*
Yes
No
Are they eating more, less or not at all?
More
Less
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
Submit
Feedback on this form?
Send your thoughts to marketing@bbvsh.com
Should be Empty: