Medical History Form printable pdf download

Larchmont Animal Hospital

2061 Palmer Avenue

Larchmont, NY 10538

(914) 834-0199 fax: (914) 834-0310

Medical History Form

In order to help us provide your pet with the best care possible, please fill out this medical history form. Please give us the most

accurate assessment possible – remember, your pet can’t tell us how he or she is feeling!

Owner’s Name: _______________________ Pet’s Name: ____________________ Date: _______________

Phone number(s) where you can be reached today:

_____________________________________________________________________________

REASON FOR VISIT/BRIEF DESCRIPTION OF SYMPTOMS:

WHEN DID THE SYMPTOMS START?:

HAVE THESE SYMPTOMS OCCURRED BEFORE? IF YES, WHEN?

PLEASE CHECK EACH OF THE FOLLOWING:

APPETITE: Good ____ Fair ____ Poor ____ None ____ LAST FED: ______________________________________

DRINKING: Normal ____ Increased ____ Decreased ____ None ____ LAST DRANK: ________________________

BOWEL MOVEMENTS: Normal ____ Hard ____ Soft ____Diarrhea ____ Other: ____________________________________________

VOMITING: No ____ Yes ____ If yes, how long/frequency ____________________________________________________________

URINATION: Normal ____ Abnormal (please describe) _____________________________________________________________

COUGHING: No ____ Yes ____ How long/often _______________ SNEEZING: No ____ Yes ____ How long/often ________________

BLEEDING: No ____ Yes ____ How long/From where? ______________________________________________________________

OTHER DISCHARGE: No ____ Yes ____ How long/From where? ________________ Consistency: ____________

IS YOUR PET ON ANY MEDICATIONS? No ____ Yes (please list) ________________________________________________________

____________________________________________________________________________________________________________

HEARTWORM PREVENTATIVE? No ____ Yes (please specify product) ____________________ Last given: ______________

FLEA/TICK PREVENTATIVE? No ____ Yes (please specify product) _______________________ Last given: ______________

*note: If your pet has internal or external parasites (fleas, ticks, intestinal parasites, etc.), he or she will be treated at your expense.

DOES YOUR PET GO OUTSIDE UNSUPERVISED? No ____ Yes ____

ANY OTHER SERVICES TO BE PERFORMED WHILE YOUR PET IS HERE?

I certify that I am the owner of the above described animal, or the owner’s authorized agent. I authorize Larchmont Animal Hospital

to treat my pet, and understand that payment in full is required at patient discharge. If I leave my pet at Larchmont Animal Hospital

for care, I authorize emergency medical treatment if necessary. If my pet has internal or external parasites, or is not current on

vaccinations and parasite testing, he or she will be treated at my expense. I authorize the use of sedation or anesthesia for handling

and/or treatment of my pet, and authorize any lab work necessary for the administration of these medications.

_________________________________________________________

_______________________________________________

Owner or Owner’s Agent Signature

Today’s Date

Medical History Form