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Internal Medicine History Form

    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?
    CannedDryTable Food
    Brand:

    Are vaccinations current?
    YesNo

    Has your pet traveled out of the state in the last six months?
    YesNo

    Are there other pets in your household?
    YesNo
    Describe:

    Current Medication

    Heartworm Prevention:
    Monthly HeartguardMonthly Interceptor

    Other Medications (describe):

    Any unusual reactions to medications?
    YesNo
    Describe:

    Changes in Normal Activity

    Appetite:
    NoIncreasedDecreased
    Describe:

    Water Intake:
    NoIncreasedDecreased
    Describe:

    Weight:
    NoIncreasedDecreased
    Describe:

    Urination:
    NoIncreasedDecreasedStrainingBlood in urineUnusual odor to the urine
    Describe:

    Bowel Habits:
    NoIncreasedDecreased
    Describe:

    Vomiting:
    NoDailyWeeklyMonthlyIntermittent
    Describe:

    Coughing:
    NoDailyWeeklyMonthlyIntermittent
    Describe:

    Sneezing:
    NoDailyWeeklyMonthlyIntermittent
    Describe:

    Seizures:
    NoDailyWeeklyMonthlyIntermittent
    Describe:

    Changes in walking:
    YesNo
    Describe:

    Skin changes:
    YesItchingNo
    Describe:

    Swelling or tumors:
    YesNo
    Describe:

    Vaginal discharge:
    YesItchingNo
    Describe:

    Any other changes? (describe):

    Additional Comments

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