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
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: hartfordanimal@sbcglobal.net

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