Animal Hospital of Orwell Pet Medical History Form

Pet Medical History Form
Client Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Scheduled Appointment Information
Do you have an appointment for your pet?
If you do not have an appointment, please call the clinic or use our appointment scheduler.
The reason for your pet's appointment is due to the following:
Pet Information
Pet's Name
Type of Pet

Other
Breed
Age or Birthdate
Gender
Color
Where does your pet spend most of it's time:
How many pets are in your household
What brand and type of pet food do you feed your pet?
I feed:
How is your pet's appetite?

Other
How is your pet drinking water?

Other
Do you notice any of the following? (Check all that apply)

Other
Medical History

Please answer questions below and provide any relevant medical history for your pet in the comments section.
Has your pet been to our veterinary practice before?
Previous Veterinarian where past medical records may be obtained if necessary.
I consent the release of my pet's medical information to Animal Hospital of Orwell.
(enter name as signature)
Vaccination Record

Cancelof
Medical Conditions
Has your pet had a dental examination and cleaning?
When and where did your pet have a dental examination and cleaning?
Has your pet had a heartworm test?
When did your pet have a heartworm test?
Has your pet had a Lyme test?
When did your pet have a Lyme test?
Has your pet had a feline leukemia test?
When did your pet have a feline leukemia test?
Has your pet had a fecal test?
When did your pet have a fecal test?
Has your pet had blood testing for kidney and liver functions?
When did your pet have blood testing for kidney and liver functions?
Has your pet been vaccinated for rabies in the past 12 months?
When and by whom did your pet have a rabies vaccination?
Has your dog been vaccinated for canine distemper in the past 12 months?
When and by whom did your dog have a canine distemper vaccination?
Has your dog been vaccinated for kennel cough in the past 12 months?
When and by whom did your dog have a kennel cough vaccination?
Has your dog been vaccinated for Lyme in the past 12 months?
When and by whom did your dog have a Lyme vaccination?
Has your cat been vaccinated for feline respiratory in the past 12 months?
When and by whom did your cat have a feline respiratory vaccination?
Has your pet been vaccinated for feline leukemia in the past 12 months?
When and by whom did your cat have a feline leukemia vaccination?
Has your pet bitten anyone or anything in the past 10 days?
Has your pet been dewormed in the past 6 months?
When and and what type of dewormer?
Has your pet received flea and/or tick prevention in the past year?
When and what type of flea/tick preventative?
Has your pet received heartowrm prevention in the past year?
Current medications your pet is taking:
When and what type of heartworm preventative?
My signature below is that I agree with all items with my name above in this documentture
Date

MonthDayYear
Date
Additional Comments
The clinic I am filling out this form for is:
Should be Empty:

Pet Medical History Form

Client Information

Scheduled Appointment Information

Pet Information

Medical History