Medical Intake form

HEALTH HISTORY QUESTIONNAIRE
NAME OF ANIMAL
GENDER
AGE
BREED / DISCIPLINE
ATTENDING VETERINARIAN
DATE OF LAST EXAM
RECENT CHANGES IN HEALTH (IF ANY)
NAME OF OWNER

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HEALTH HISTORY

IMMUNIZATIONS

Rows	Yes	No	Date
Tetanus (TdaP)
Influenza (Flu)
Rabies
West Nile

Other Immunizations:
Worming (type & date of last dose):
List any medical problems that have been diagnosed by a veterinarian:

SURGERIES

Rows	Year	Reasons	Diagnosis or Treatment
1
2
3
4

OTHER INJURIES OR CONDITIONS

Rows	Date	Symptons or Cause	Diagnosis or Treatment
1
2
3
4

ALLERGIES

Rows	Drug or Other Cause	Reaction
1
2
3
4

MEDICATIONS & SUPPLEMENTS

Rows	Name	Purpose	Dose & Frequency
1
2
3
4

If others, please list.
HEALTH HABITS
EXERCISE

Other
DESCRIBE ACTIVITIES – frequency, training type, challenges in work, recent activity, etc
DESCRIBE BEHAVIOR – recent changes, temperament, etc

DIET

Rows	Type	Amount	Frequency
Forage
Grain
Fat Supplement

FAMILY HISTORY

Rows	Name	Significant Problems	Age
Dam
Sire
Female Siblings
Male Siblings

GENERAL HEALTH

Rows	Yes	No	Describe
Is the animal receiving physical therapy for a condition? If yes, describe
Is the animal eating and drinking normally? If not, describe.
Has the animal received massage before?
Does the animal adopt a specific posture regularly? (describe)
Does the animal appear to sleep comfortably?
Is the animal restricted to stall rest?
Does the animal require bandaging? (describe)
Does the animal require hydrotherapy? (describe)

OTHER PROBLEMS

Rows	Symptoms	Changes	Describe
Skin
Head / Neck
Ears
Nose
Throat/Lungs
Chest /Heart
Back
Intestinal
Bladder
Genitals
Circulation
Weight
Energy Level
Performance
Other

Is there any additional information you would like to share?
Should be Empty: