Medical History Form – Veterinarians in Oviedo, Florida

Name*

First Last

Email*

Phone*

Name of Pet:

Species

Cat
Dog

Breed

Gender

Female
Male

Spayed or neutered?

No
Yes

If so, when?

Approximate age

Approximate weight

Who is your current primary care veterinarian (Name of doctor and clinic)?

Why are you being referred?

Have the symptoms...

Worsened
Improved
Stayed the same

Previous medications tried?

While on medications, the symptoms…

Current medications (including prescription medications, over the counter medications, nutraceuticals, vitamins, herbs, etc). Please bring medications in original vials with you to your appointment.

Any anti-inflammatory drugs, steroids, or antibiotics in past week?

Yes
No
Unsure

Previous medical problems or surgeries?

Any history of anesthesia complications?

Yes
No

If yes, please describe:

Any history of drug reactions/allergies?

Yes
No

If yes, please describe:

What food do you feed your pet on a daily basis?

How much does your pet eat per day?

Has this:

Decreased
Increased
Stayed the same

Have you noticed any change in body weight?

Decreased
Increased
Stayed the same

Has the amount of water drank changed?

Decreased
Increased
Stayed the same

If the amount of water consumtion has changed, please specify when this change was noticed:

Please check any of the following changes in urinary habits?

Straining to urinate
Urinating more frequently
Small amounts?
Or large amounts?
Dribbling urine
Blood in urine
Finding puddles of urine where sleeping

Urinating outside litter box (if cat)?

Yes
No

Urinating in house?

Yes
No

Any throwing up?

Yes
No

If yes, how often and when did it start?

What is being thrown up?

How many hours after eating does vomiting occur?

Is there retching/heaving or excessive salivation?

Yes
No

Any straining to defecate?

Yes
No

Is the feces well formed?

Yes
No

Is the feces too soft?

Yes
No

Any mucus?

Yes
No

Any blood?

Yes
No

Any incontinence?

Yes
No

If a cat, is it defecating outside of litter box?

Yes
No
Not applicable (dog)

Any coughing?

Yes
No

If so, any particular time of day?

Any Sneezing/nasal discharge?

Yes
No

If yes, any:

Mucus?
Blood?
Clear?

Have you ever seen any fleas/ticks?

Yes
No

What flea/tick/heartworm prevention do you use?

When was it last given?

History of seizures?

Yes
No

Any lameness, limping, trouble getting up or walking?

Yes
No

How much time (percentage) does your pet spend indoors?

Has you pet traveled outside of Florida?

Yes
No

If yes, when and where?

Any exposure to other animals (i.e. grooming, kennel, dog/cat shows) in the last month?

Yes
No