Medical History Form printable pdf download

MEDICAL HISTORY FORM

Owner Name: ___________________________________________________________________________

Pet Name: ____________________________________________ Date: ____________________________

Please briefly describe your main concerns today (Include when things started and if getting worse or better):

_______________________________________________________________________________________

What does your pet eat? (please use brand names, dry vs. wet and include treats and table scraps)

_______________________________________________________________________________________

Is your pet’s appetite:

Normal

Decreased

Absent

When & what did your pet last eat? __________________________________________________________

Has your pet’s attitude been: Normal

Quiet

Depressed

Over active

For how long? ___________________________________________________________________________

Is your pet vomiting?

Yes

No

How many times daily? ________________________When did it start? _____________________________

Vomit is: foam

food

hair

blood

yellow fluid

coffee grounds

Other (please describe) __________________________________________________________________

Yes

No

Does your pet have diarrhea?

How many times daily? ___________________________ When did it start? _________________________

Diarrhea is:

soft, mushy stool

pea soup

watery

blood

mucous

Black and tarry

other (describe) ______________________________________________________

Is your pet coughing?

Yes

No

How many times daily? _______________________ When did it start? _____________________________

Is cough worse:

with exercise

at night

when eats/drinks

Has your pet had contact with other animals in the past 2 weeks? ___________________________________

Yes

No

Is your pet sneezing?

How many times daily? ___________________________ When did it start? _________________________

Does your pet sneeze:

blood

water

mucous

in violent fits

Is your pet drinking more than usual?

Yes

No

Is your pet urinating differently than usual?

Yes

No

Urination is:

frequent small amounts

large amounts

bloody

in unusual places

What treatments have already been attempted? _________________________________________________

_______________________________________________________________________________________

162 Cross Street

San Luis Obispo, CA

(805) 545-8212

Medical History Form

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