Nurse Visit/Wellness Care Form - Redwood Veterinary Hospital Inc.

Medical History- Nurse Visit/Wellness Care

All Fields Marked with * are required and must be filled.
Please remember that Nurse Visits are intended for routine health and wellness care. Nurses do not provide medical diagnoses or prescribe treatment. If your pet has a medical problem or concern, please call and reschedule your appointment with a doctor at (707) 553-1400.
Pet Owner's Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Pet's Name*
What kind of pet do you have?*

CatDogOther
Age of Pet*
Breed*
Color*
1. What are we seeing your pet for?*
2. If your pet is being seen for a medical concern or problem, has long has it been going on?
3. Unless detailed in #1 above, have you noticed any recent changes in your pet's appetite or energy level? Please explain:
4. Unless detailed in #1 above, have you noticed any recent vomiting, diarrhea, coughing or sneezing by your pet? Please explain:
5. Unless detailed in #1 above, have you noticed any recent change in your pet's urination or bowel habits? Please explain:
6. Does your pet have any past, or ongoing major medical issues?
7. Has your pet experienced any adverse reactions to medications or vaccinations? If so, please explain below. Please include the medications/vaccines that caused the reaction(s), what the reactions looked like (gastrointestinal/respiratory signs, swelling, etc.) and the approximate dates of the reaction(s).
8. Currently, does your pet take any medications (including Heartworm Preventatives), supplements or eat a prescription or special diet? Please explain and include the name, strength, and frequency of dosing any medication(s), if possible.
9. Currently, is your pet on a flea/tick control product? Please explain:
10a. CATS ONLY: Does your cat go outside of the house?

YesNo
10b. CATS ONLY: Do any other cats in the household go outside of the house?

YesNo
Vaccination History
If your pet received its most recent vaccines from a hospital or veterinary service other than Redwood Veterinary Hospital, please provide dates below if possible: If you have vaccine records from another hospital, please submit them electronically--Email to redwoodvet@yahoo.com. (please clearly identify these emailed records with your name and your pet’s name)
A. Dogs
DHPP (Distemper, Hepatitis, Parainfluenza, Parvo)

MonthDayYear
Date
Rabies

MonthDayYear
Date
Leptospirosis

MonthDayYear
Date
Bordetella (“Kennel Cough”)

MonthDayYear
Date
Canine Influenza

MonthDayYear
Date
B. Cats
FVRCP (Upper Respiratory Viruses, Panleukopenia)

MonthDayYear
Date
Rabies

MonthDayYear
Date
Feline Leukemia

MonthDayYear
Date
11. Does your pet need any prescription medication refills (Prescriptions, Heartworm/parasite/flea-tick control, etc.)? Please explain:
12. What other concerns would you like us to address during your pet's visit?
Should be Empty:

Medical History- Nurse Visit/Wellness Care

Vaccination History