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