Medical History Form

Medical History

Thank you for filling out this form and helping our staff prepare for your visit. 15 questions.
Your Pet's Name*
Your Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of your appointment*

MonthDayYear
Date
Address (if changed since last visit)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
So that we may assess disease risk and customize our health recommendations for your pet, please indicate any of the following that apply.*

My Dog goes to dog parksMy Dog goes to a boarding kennel or doggie day careMy Dog goes to a groomerMy Dog goes to training classes or dog sporting eventsMy Dog goes camping and/or hikingMy Dog doesn't interact with other dogs outside of my familyMy dog occasionally interacts with other dogsMy Cat is strictly indoors and NEVER slips outsideMy Cat goes outside on a porch or deck and never touches the grassMy Cat is indoor/outdoor or escapes to the outdoors
Please list all medications, parasite preventives, supplements, and vitamins your pet is currently taking. Please include Name, dosage, and frequency:*
Write NONE if your pet is not currently on medications, supplements, or vitamins.
Please list any medications you will need refilled at your appointment or write none?*
Write NONE if your pet does not need any refills.
Please list all of your pet's known allergies to Medications, vaccines or food.*
Write NONE if your pet has no allergens.
Please list the type, brand, and amount of food your pet receives. Please include treats. *
Is your pet on a grain-free or raw diet? Select all that apply.

RawGrain-FreeNo, my pet is not on a raw or grain-free dietUnknown
Please check all symptoms that your pet is currently experiencing. Explain details in the space below.*

Vomiting (describe frequency below)Diarrhea (describe frequency below)ConstipationSneezingCoughingDecreased mobilityLameness or limpingLethargyAppetite changes (please describe below)Concerns about pet's weight (increase or decrease)Increased drinking/water intakeIncreased urination amount or frequencyUrinary or stool accidents in the houseEye problemsSkin and/or ear problemsMouth or tooth problemBehavioral changes (please describe below)None, my pet seems healthy and I have no concerns
Please provide details about your concerns. Please list the date concerns began (duration, frequency, severity, etc.). List any additional information you feel may be helpful to the doctor.
Would you like information about our Wellness Plans for puppies/kittens, adult pets, and/or senior pets?

YesNoMy pet is already on a Wellness Plan
Do you have any upcoming travel plans with your pet?

Yes, travel within the United StatesYes, international travelNo
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