Internal Medicine Patient History Form

Owner Name *

First

Last

E-mail: *

Patient Name *

Problem/Complaint: *

List ALL clinics that have seen your pet for the problem/complaint listed above:

Is your pet up-to-date on vaccines?

• Yes
• No

Past Treatments for current problem:

Medications: Please include Dose (mg), How often given, Last given:

What are you feeding your pet? (include treats) Please specify brand, amount, how often:

Where did you get your pet?

Any travel outside of PNW?

In recent history have you noticed any changes in… (check what applies)

• Drinking
• Appetite
• Weight
• Energy
• Urination
• Defecation
• Coughing
• Sneezing
• Vomiting

Drinking:

• Increased
• Decreased
• Normal

Appetite:

• Increased
• Decreased
• Normal

Weight:

• Increased
• Decreased
• Normal

Energy:

• Increased
• Decreased
• Normal

Urination:

• Increased
• Decreased
• Normal

Defecation:

• Increased
• Decreased
• Normal

Coughing:

• Increased
• Decreased
• Normal

Sneezing:

• Increased
• Decreased
• Normal

If your pet is vomiting, how often is it happening?

Describe any of the abnormal above:

Website

Submit