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