Pre-Visit Medical Form

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Owner name

Phone

Today's Date

Pet's Name

Please describe the current problem with your pet.

How long has this been going on?

How has your pet been eating?

What kind of food and how much does your pet normally eat?

How has your pet been drinking?

Has there been any vomiting? If yes, how often, for what duration? What is the consistency/nature of the material vomited up?

Has there been any diarrhea? If yes, how often is it occurring? What is the consistency of the diarrhea? Have you noticed any blood or black, tarry material?

Has your pet been urinating more or less than normal? Does your pet appear painful when urinating? Have you noticed any changes to the appearance of the urine?

Is your pet taking prescription medications or supplements? Have you given your pet any over-the-counter medications recently?

Are you currently giving your pet heartworm and flea and tick preventatives?

Yes

Does your pet have any chronic health issues?

If your pet is a cat, does your cat go outside, even intermittently?

Yes

Has your pet been exposed to anything abnormal such as non-prescribed medications, new foods, garbage, etc?

Yes

If Crosslake Veterinary Hospital is not your primary care veterinarian, who is your regular veterinarian and may we request medical records?

Has your pet been seen at another veterinary hospital since their last visit with us?

Yes

Please provide the veterinary clinic's name and phone number

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Pre-Visit Medical Form

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