Comprehensive Patient Medical History Form

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Comprehensive Patient Medical History Form
Payment today by:
Yes
No
 Cash
 Check
 Credit Card
1. Is your address and phone number current?
Reason for visit today
2. Do you have pet health insurance?
3. Are your pet’s vaccinations up to date?
4. Is your pet spayed or neutered?
Has your pet been examined elsewhere for
the same condition?
 Yes
 No
5. Was there a heartworm test in the last year?
If so where?
6. Is your pet taking heartworm prevention?
What medications is your pet now taking?
7. Has your pet been tested for worms in the last year?
8. Has your pet had any illness/injury in the last year?
9. Has your pet ever had a seizure or behavioral problem?
Is your pet allergic to any food, medications, or
treatment?
 Yes
 No
10. Does your pet get table scraps? Type of food ________
11. Did your pet eat in the last four hours?
If yes, please describe
12. Any change in the nature of urine or urinating?
What heartworm prevention is your pet on?
13. Has there been any recent vomiting?
14. Has your pet been coughing, sneezing, or gagging?
What flea control is used?
15. Any listlessness, weakness, or lethargy?
16. Any weakness?
Your pet is: ________Indoors _______Outdoors
17. Any lameness? Circle leg RF LF RR LR
Other pets in the household?
_______Dogs
_______Cats
_______Exotics
18. Any Shaking? Where? __________________________
Travel with your pet? Yes No Where? ________
19. Any Scratching? Where? ________________________
Anything else we need to know?
20. Any hair loss? If so, where? _____________________
21. Any Scooting of rear? __________________________
22. Unusual lumps or bumps?
23. Bad breath?
24. Any Unusual discharge? Where? _________________
25. Any Diarrhea? Or Constipation?
I hereby authorize the hospital to prescribe for
26. Any Stiffness _____ or Pain ____ Where? __________
and treat the conditions presented on this form
for the pet presented by me. The hospital and
27. Behavioral Changes?
staff will not be held liable for any problems
that develop provided that reasonable care is
Same?
Increased?
Decreased?
provided. Further I agree to pay fees in full for
Drinking
services rendered when pet is discharged from
the hospital’s care.
Appetite
Urination
Defecation
Signature
Date
Weight

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