Medical History Form

This form will be used for any wellness examination on a pet.

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Owner's Name

First Last

Pet's Name

Is your pet indoors only, outdoors only, or both?

Indoors

Outdoors

Do you have any other pets?

Yes

No

Please Describe

Do you travel with your pet or have other animals visit?

Yes

No

Does your pet go to the groomer or any boarding facility?

Yes

No

Does your pet have a microchip and is up-to-date for your contact information?

Yes

No

What brand does your pet consume, the amount consumed in a day and is your pet given any treats?

Does your pet have bad breath, drooling, or difficulty eating?

Yes

No

Has there been any changes in stools or urination (color, consistency, frequency, amount, straining, accidents etc.) in the past 12 months?

Yes

No

If YES please describe

It is recommended that your pets feces be tested annually for internal parasites. Opt-out:

Yes

No

Has your pet had any vomiting or regurgitating in the past 12 months?

Yes

No

Is your pet currently on any preventatives? These include flea, tick, heartworm, gastrointestinal parasites, ear mites, etc

Yes

No

If YES, please describe.

If given preventives, has your pet missed any doses or have they been discontinued at any point?

Has your pet been tested for heartworms and other bloodborne pathogens (Anaplasma, Ehrlichia, and Lyme for dogs or Feline Leukemia Virus and Feline Immunodeficiency Virus for cats) in the past 12 months?

Yes

No

An annual heartworm check is required if on heartworm preventative. Opt-out

Yes

No

Has your pets blood and/or urine been tested for liver, gall bladder, pancreas, kidney, bladder health, thyroid, red blood cells, white blood cells and platelet values in the past 12 months?

Yes

No

Does your pet currently take any medications or supplements?

Yes

No

If YES, please describe.

Has your pet been sick, ill, or had any surgeries in the past 12 months?

Yes

No

If YES, please describe.

Phone

Address

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