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
Check if your pet has had any...*

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
Please check if your pet has had any...*

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
Please check if your pet has had any...*

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
Check any that apply to your pet*

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
Please check all that apply to your pet*

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)...
Has your pet shown any of the following signs of fear, anxiety, or stress at your veterinarian's clinic?

Growling, hissing, lunging, or bitingNeed of a muzzleNeed for anti-anxiety medications prior to veterinary visitsNone of the above
Include other comments regarding your pets Medical History
Should be Empty:

Patient Medical History

Cardiovascular/Respiratory History

Gastrointestinal History

Neurologic/Orthopedic History

Infectious Disease History

Urinary History