Medical History Form – Country Doctor Veterinary Hospital

Country Doctor: Medical History Form

In order for your veterinary healthcare team to provide comprehensive care for your pet, please fill in this form and return via email prior to your visit.

Date:*
dd/mm/yyyy
Owner's Name
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Day-Time Phone*
Evening Phone
Mobile Phone
Email*
Pet Information
Pet's Name*
Species*
if other please specify
Breed (if known)
Sex
Color
Date of Birth or Age (if known)
Pet Health - Reason for Visit
Describe your concern or questions you would like to discuss with the Doctor.*
How long has this been going on?*
Days/Weeks/Months
What are you currently feeding the pet?*
food/treats
How is their appetitie?*
poor/good/excellent
Are you currently giving any medications or supplements?*
- yes
- no
Please specify*
name/dose/last given
Any coughing or sneezing?*
- yes
- no
Please describe*
Any vomiting or diarrhea?*
- yes
- no
Please describe*
Have they gotten into anything? Eaten anything unusual?*
- yes
- no
Please describe*
What kind of environment does your pet live in/near?*
For example: Do they spend time in the woods? Or are they exposed to open water?
Is your pet indoors only? (Cats)
Any environmental changes?*
Describe their behavior*
lethargic/normal/hyperactive
Any changes to thirst?*
increased/normal/decreased
Any changes to urination?*
increased/normal/decreased
How are their bowel movements?*
normal/abnormal
When was their last bowel movement*
Do you have pet insurance and if so what type?
If yes, list the type of insurance you have in the field below.

Country Doctor: Medical History Form

Owner's Name

Pet Information

Pet Health - Reason for Visit

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