Comprehensive Pet Medical History Form
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1DeZavala-Shavano Veterinary Clinic
Comprehensive Pet Medical History Form
NAME OF PET:
Yes
No
Reason for visit today ______________________________
Are your pet's vaccinations up to date?
_________________________________________________
Has your pet ever had a reaction to vaccines?
Vaccination history? ________________________________
Was there a heartworm test in the last year?
_________________________________________________
Is your pet taking a heartworm prevention Rx?
*** Please provide vaccination history, if possible. ***
Has your pet been tested for worms in the last year?
We will gladly make a copy for your pet's records.
Have you seen your pet passing any worms?
Pet’s diet? ________________________________________
Has your pet had any illness/injury in the last year?
Health problems or behavioral tendencies? ______________
Has your pet ever had a seizure?
_________________________________________________
Does your pet get table scraps?
Does your pet ever strain to urinate?
What medications is your pet now taking? _______________
_________________________________________________
Has there been any recent vomiting?
_________________________________________________
Has your pet been coughing?
Has your pet been sneezing?
Is your pet allergic to any food or Rx?
Yes
No
Has your pet been gagging?
If yes, please describe _______________________________
Any listlessness?
What heartworm prevention is used? ___________________
Any weakness?
Any lameness?
Circle leg: RF LF RR LR
What flea control is used? ___________________________
Shaking of the head?
Anything else we need to know? ______________________
Scratching?
Where?
_________________________________________________
Significant hair loss?
Scooting of rear?
Unusual lumps or bumps?
While uncommon, adverse reactions to vaccines, injections
and medications can occur. Typical symptoms include
Bad breath?
swelling, itching and vomiting; however, in rare cases,
Unusual discharge?
collapse, seizures and death can occur. We encourage you to
Diarrhea?
discuss any concerns you have regarding administering
vaccines, injections or medications to your pet with one of our
Constipation?
doctors.
Stiffness?
I hereby authorize the Clinic to prescribe for and treat the
Behavioral Changes?
conditions presented on this form for the pet presented by me.
The Clinic and staff will not be held liable for any problems
Increased?
Decreased?
that develop provided that a reasonable standard of care is
provided. Further, I agree to pay fees in full for services
Drinking?
rendered when pet is discharged from the Clinic’s care unless
Appetite?
prior arrangements have been agreed upon by both parties.
Urination?
_____________________________________________________________
Defecation?
Signature
Date
Weight?
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Parent category: Medical