Medical History Questionnaire

Date

Owner's Name *

First

Last

Pet's name *

First time this pet has been here? *

Yes
No

Type of Pet

Age

Color

Does your Pet have Health Insurance? *

Yes
No
** I'd like some information on Health Insurance

Purpose of Visit *

Details about your pet's condition? Special needs for you or your pet?

** Please keep your pet from urinating for 3 hours prior to your visit if possible. (Close doggy doors or prevent access to the litterbox)

MEDICAL HISTORY

Please fill in the health questions below so we can be sure to cover everything while your pet is here. This also helps us keep your pet's record up to date between visits!

LIFESTYLE *

Please check all that apply

Please explain additional details of your pet's environment, if you like

Diet/ Nutrition *

Brand of food

How is your Pet's Appetite/ Drinking? *

Normal
Abnormal

Please explain Abnormalities in Eating or Drinking

How are your Pet's Eliminations (Urine and Stool)? *

Normal
Abnormal

Please explain abnormalities in your pet's Eliminations

Has Your Pet Shown Any of the Following Signs? *

Please explain any conditions checked above

Please list an Medications, Supplements your pet is Currently Taking

Remember Heartworm Preventives, Flea/Tick Protection, Vitamins and Natural supplements *