Symptom History Form

Before your first appointment, please complete and submit the form below. Observe your animal closely to gather current information that is as specific and accurate as possible.

Be sure to check the last box and email a copy to yourself.

1. Your Name(required)
2. Your Pet's Name(required)
3. Current problem:
4. Current medications: (dosage, frequency, how long, effects, side-effects, etc.)
5. Prior occurrences and treatment: (other vets, when young, home treatments, etc.)
6. Past history of illness; even minor: (ear infections, cystitis, skin problems, vomiting or diarrhea, upper respiratory, teeth, etc.)
7. Vaccination history: (what, when, how often, side effects, etc.)
8. Temperature preferences: (prefers under covers, on cool floor, in sun, etc.)
9. Bowel movements: (color, frequency, hard, soft, straining, etc.)
10. Mouth problems: (gum color, odor, tartar, gingivitis, lost teeth, etc.)
11. Urination habits: (color, frequency, time, straining, unusual places, etc.)
12. Diet and food preferences: (brand name, type, time of day, etc.)
13. Appetite and cravings: (finicky, ravenous, acts hungry but eats little, only eats dry food, etc.)
14. Thirst: (quantity, frequency, sources, temperature preferences, etc.)
15. Skin and Coat: (rough, oily, dry, dandruff, odor, fleas, lumps, warts, color change, etc.)
16. Ears: (discharge, wax, odor, itchy, inflammation, etc.)
17. Personality and behavior: (sweet, nervous, independent, reactions to strangers, other animals, noises, sudden changes, etc.)
18. Idiosyncratic habits: (odd behaviors, licking feet, snapping at flies, hiding, etc.)
19. Other: (change of location, friend died, new baby, trauma, etc., as well as other symptoms not covered)
20. Your Email(valid email required)
21. Have a copy of this form emailed to you.

 

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