Medical History Form

Medical History Form

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

Date:*
dd/mm/yyyy
Due to the COVID-19 prevalence, we want to ensure your safety, and that of our team. Please answer yes/no to these questions:
*Please note: Answering yes does NOT prohibit your pet from being seen if they are ill but allows us to put appropriate safety parameters in place for our team and doctors.
Do you, or someone in your household, have symptoms consistent with COVID-19, a fever, cough, or difficulty breathing?*
- Yes
- No
Have you, or someone in your household, been exposed to someone who has tested positive for COVID-19?*
- Yes
- No
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*
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, sneezing, nasal discharge, or other respiratory signs?*
- yes
- no
Please describe*
Any vomiting or diarrhea?*
- yes
- no
Please describe*
Any limping, pain, stiffness or other mobility issues?*
- Yes
- No
Please describe*
Any skin issues?*
- Yes
- No
Please describe*
Have they gotten into anything? Eaten anything unusual?*
- yes
- no
Please describe*
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
If your pet has any masses that concern you, please describe:*
Please use this comment section to include any questions or concerns you have.*
Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY

Contact

1191 Grand Avenue
Hartford, WI 53027

Phone: (262) 673-7960
Fax: (262) 673-5804
Email: [email protected]

Clinic Hours

Monday: 7:30am – 6:00pm
Tuesday: 7:30am – 6:00pm
Wednesday: 7:30am – 6:00pm
Thursday: 7:30am – 6:00pm
Friday: 7:30am – 6:00pm
Saturday: 7:30am – 12:00pm
Sunday: Closed

Emergencies

Wisconsin Veterinary Referral Center
Waukesha Location: (866) 542-3241
Grafton Location: (262) 546-0249
www.ethosvet.com

Blue Pearl
Port Washington: (262) 268-7800
Glendale: (414)-540-6710
www.blupearlvet.com

Animal Poison Control
Veterinary toxicologists available 24 hours a day
888-426-4435

Home
New Clients
About Us
Services
Pet Health
My Pet
Contact Us