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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

    Suite 6

    Suite 5

    Suite 4

    Suite 3

    Suite 2

    Suite 1

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