Internal Medicine Patient History Form Please complete this form prior to your pet’s appointment. Please enable JavaScript in your browser to complete this form.Owner Name *FirstLastE-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?YesNoPast 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) DrinkingAppetiteWeightEnergyUrinationDefecationCoughingSneezingVomitingDrinking: IncreasedDecreasedNormalAppetite:IncreasedDecreasedNormalWeight:IncreasedDecreasedNormalEnergy:IncreasedDecreasedNormalUrination:IncreasedDecreasedNormalDefecation:IncreasedDecreasedNormalCoughing:IncreasedDecreasedNormalSneezing:IncreasedDecreasedNormalIf your pet is vomiting, how often is it happening?Describe any of the abnormal above: PhoneSubmit