Patient Medical History Form

Patient Medical History
Pet's Name*

First NameLast Name
Owner's Name *

First NameLast Name
List your primary care veterinarian and any other hospitals that your pet has been seen at within the last 3 years*
List the primary reason for visit to Veterinary Specialty Solutions*
Cardiovascular/Respiratory History
CoughingIncreased respiratory rate or effortExercise intoleranceCollapsing episodesNasal dischargeSneezingNoisy breathingNone of the above
If you checked yes to any of the above, please describe (how often? when did it start?)
Gastrointestinal History
Please specify diet and amount being fed
Change in appetiteWeight lossVomitingDiarrheaFecal incontinenceStraining to defecate/constipationDifficulty swallowingNone of the above
If you checked yes to any of the above, please describe (how often? when did it start?)
Neurologic/Orthopedic History
SeizuresHead pressingHead tiltIncoordination/weaknessLamenessNone of the above
If you checked yes to any of the above, please describe (how often? when did it start?)
Infectious Disease History
Travel historyRoutine exposure to other pets (grooming, boarding, etc)Other pets or people in household sickCurrently on flea, tick, heartworm preventionNone of the above
If you checked yes to any of the above, please describe (how often? when did it start?)
Urinary History
Increased thirstIncreased urinationUrinating inside house (dogs) or outside litter box (cat)Dribbling urine involuntarilyNone of the above
If you checked yes to any of the above, please describe (How often? When did it start?)
Other illnesses:
Please list any drug allergies, if none - please write 'N/A' or 'None'.
Please list any Operations and Dates of Each that your pet has had...
Please list your pet's Current Medications (include dose and how often given)...
Growling, hissing, lunging, or bitingNeed of a muzzleNeed for anti-anxiety medications prior to veterinary visitsTrembling, tail tucking, or flattening earsAvoidant or hiding from veterinary nurses or doctorsNone of the above
If you checked yes to any of the above signs of fear or stress we recommend the use of anti-anxiety medications prior to your veterinary visit (such as Gabapentin in cats and Trazodone in combination with Gabapentin in dogs).
Include other comments regarding your pets Medical History
Filling out this form will not schedule an appointment or prompt our office to call you. Please call our office directly to make an appointment.
Should be Empty:

Patient Medical History

Cardiovascular/Respiratory History

Gastrointestinal History

Neurologic/Orthopedic History

Infectious Disease History

Urinary History