Patient Information and Medical History

Current Problem and Medical History

Your Name:

Your Email:

Pet’s Name:

Date:

Why are you bringing your pet to BEVS for an Internal Medicine consultation?

How long has your pet been sick?

List any medical problems or procedures that have occurred within the last two years: (include any surgery, trauma, etc…)

General Information

How long have you owned your pet?

What is your pet’s diet?
 Canned Dry Table Food
Brand:

Are vaccinations current?
 Yes No

Has your pet traveled out of the state in the last six months?
 Yes No

Are there other pets in your household?
 Yes No
Describe:

Current Medication

Heartworm Prevention:
 Monthly Heartguard Monthly Interceptor

Other Medications (describe):

Any unusual reactions to medications?
 Yes No
Describe:

Changes in Normal Activity

Appetite:
 No Increased Decreased
Describe:

Water Intake:
 No Increased Decreased
Describe:

Weight:
 No Increased Decreased
Describe:

Urination:
 No Increased Decreased Straining Blood in urine Unusual odor to the urine
Describe:

Bowel Habits:
 No Increased Decreased
Describe:

Vomiting:
 No Daily Weekly Monthly Intermittent
Describe:

Coughing:
 No Daily Weekly Monthly Intermittent
Describe:

Sneezing:
 No Daily Weekly Monthly Intermittent
Describe:

Seizures:
 No Daily Weekly Monthly Intermittent
Describe:

Changes in walking:
 Yes No
Describe:

Skin changes:
 Yes Itching No
Describe:

Swelling or tumors:
 Yes No
Describe:

Vaginal discharge:
 Yes Itching No
Describe:

Any other changes? (describe):

Additional Comments