Medical Exam Form History What is your biggest concern today? (Answer in box below) How long has this been a problem? Has it changed since you first noticed it? Has this been a problem in the past? YesNo Have you administered any treatments at home? NoYes What is your pet’s lifestyle? IndoorOutdoor Are there other pets in the home? NoYes Are there any changes in his/her behavior? NoYes Next What is your pet’s diet? Brand of food, amount and feeding schedule: Treats/Supplements: Increase or decrease in appetite? NoYes Increase or decrease in thirst? NoYes Is he/she vomiting? NoYes Is he/she peeing normal amount and frequency? NoYes Any change in stool color/consistency/frequency? NoYes Has your pet’s weight changed? NoYes BackNext Does your pet have any chronic medical conditions? NoYes Is your pet on any medications? NoYes Is your pet on any parasite preventatives? Flea/Tick medication: NoYes (brand, date late given) Heartworm medication: NoYes (brand, date late given) A full physical exam will be completed. Do you authorize any of the following diagnostics at this time? Bloodwork NoYesDr. discretion Urine Check NoYesDr. discretion Fecal Check NoYesDr. discretion X-rays NoYesDr. discretion BackNext Would you like any of the following services to be completed? Nail Trim NoYes Other Do you need any prescriptions filled today? NoYes (brand, date late given) Do you need any food? NoYes (brand, date late given) Do you need any other product? NoYes (brand, date late given) Phone # where you can be reached: Back Δ
