Dog Medical History Form

Please fill out in detail before dropping your pet off for an exam.



History: Please provide as much information as you can. This will help us accurately diagnose and treat
your pet. Please be as specific as possible (e.g. “right eye red and itchy for 3 days” rather than “eye
problem”).




2) Other than flea-tick medication, any other medications, nutritional supplements or herbal medications given?
YesNo



3) Coughing Recently?
YesNo






4) Sneezing Recently?
YesNo







5) Any difficulty breathing?
YesNo





6) Any Eye or Nose discharge recently?
YesNo
If yes,



7) Vomiting Recently?
YesNo









8) Diarrhea Recently?
YesNo









9) Is your pet excessively thirsty?



10) Is your pet drinking enough water?



11) Is your pet urinating normal amounts?
If No, is it more or less than normal?



12) Is your pet urinating where he or she should?
YesNo








13) Did your pet eat this morning?
YesNo



14) Is your pet eating normal amounts?
YesNo







16) Is there any possibility your pet ingested or was exposed to a household chemical or toxin, or ate a rodent or plant?
YesNo



17) Is your pet on heartworm preventative?
YesNo



18) Is your pet excessively itching/scratching?
YesNo



19) Are your pet’s ears bothering him or her?
YesNo



20) Is your pet limping?
YesNo




21) Any fleas or ticks recently?
YesNo



22) Plan to board/groom/dog show/obedience in next year?
YesNo
Town Dog Park?
YesNo
Does your pet go to PetSmart, or other large pet stores or do-it-yourself pet bathing facilities?
YesNo