Medical History Form Page 2
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2Medical History Form
Bumps, Growths or Masses
My pet has a bump, growth, or mass that has not been seen by a veterinarian before:
No
Yes
It is located:
Have any of the above been diagnosed by a veterinarian?
No
Yes
What was the diagnosis? ___________________________________________________________________________
Does Your pet have a history of the following:
Coughing
Scooting
Loss of Balance
Shaking Head
Weight Change
Sneezing
Gagging
Weakness
Bleeding
Appetite Change
Vomiting
Tremors
Vision Changes
Pain
Increased Panting
Diarrhea
Confusion
Eye discharge
Lethargy
Breathing Changes
Hairballs
Seizures
Odor
Depressed
Frequently Urinates
Vocalization
Scratching
Aggression
Biting
House Soiling
Bad Breath
Drooling
Tooth Loss
Dull Coat
Difficulty Chewing
Dandruff
Matted fur
Hair Loss
Constipation
Drinks Excessively
Sore Gums
Overweight
Underweight
Grooms Less
Urinates Large Amount
Skin allergies
Diabetes
Cancer
Urinary Tract Infections
Heart disease
Breathing Problems
Arthritis
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Parent category: Medical