Comprehensive Patient Medical History Form

Client Information

Are your address and phone number still correct?
Yes No
Do you have pet health insurance?
Yes No
Are your pet's vaccinations up to date?
Yes No
Is your pet spayed or neutered?
Yes No
Was your pet tested for heartworm in the last year?
Yes No
Is your pet taking heartworm preventative?
Yes No
Has your pet been tested for worms in the last year?
Yes No
Has your pet had any illness/injury in the last year?
Yes No
Has your pet ever had a seizure?
Yes No
Does your pet get table scraps?
Yes No
Did your pet eat in the last four hours?
Yes No
Does your pet ever strain to urinate?
Yes No
Has your pet:
 
vomited recently?
Yes No
been coughing?
Yes No
been sneezing?
Yes No
been gagging?
Yes No
been listless?
Yes No
shown any signs of weakness?
Yes No
been lame? Check leg: RF LF RR LR
Yes No
been shaking its head?
Yes No
been scratching? Where?
Yes No
had significant hair loss?
Yes No
been scooting on its rear?
Yes No
had unusual lumps or bumps?
Yes No
had bad breath?
Yes No
had an unusual discharge?
Yes No
had diarrhea?
Yes No
been constipated?
Yes No
had stiffness?
Yes No
shown behavioral changes?
Yes No
Has your pet experienced a change in any of the following?
 
Drinking?
Increase? Decrease?
Appetite?
Increase? Decrease?
Urination?
Increase? Decrease?
Defecation?
Increase? Decrease?
Weight?
Increase? Decrease?
Reason for visit today:
 
Has your pet been examined elsewhere for the same condition?
Yes No
If so, where?
 
What medications is your pet now taking?
 
Is your pet allergic to any food or medications?
Yes No
If yes, please describe:
 
What flea control is used?
 
Anything else we need to know?
 
I hereby authorize the hospital to prescribe for and treat the conditions presented on this form for the pet presented by me. The hospital and staff will not be held liable for any problems that develop provided that reasonable care is provided. Further I agree to pay fees in full for services rendered when pet is discharged from the hospital's care unless other prior arrangements have been agreed upon by both parties.
Check this box as your authorized signature.