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Medical History Questionnaire

Today's Date:

Patient and Client Information


History of Current Problem

Has your pet received any previous treatments for the primary problem?

What medications or treatments is your pet currently receiving?


What is your pet’s overall condition and symptoms?

Energy Level

Appetite

Thirst

Urination

Bowel Movement

Nausea/Vomiting

Coughing/Sneezing

Pain/Discomfort


Past Medical History

Most recent vaccines

Does your pet receive any preventative care (heartworm, flea & tick)?:
Home Life

Where does your pet spend most of their time?

What is your pet’s current diet (select all that apply)?:​​​​​​​

Does your pet receive any current treats?:

Does your pet receive any current supplements or vitamins?:

Does your pet have any housemates?

Fear Free Emotional Medical Record

Does your pet like to hide?

If yes, please describe:

ls your pet comfortable in a kennel?

If no or sometimes, please explain:

Does your pet like to chew on things?

If yes, please describe:


Client Care Record​​​​​​​

Would you like text or phone call updates of your pet while in our care?

Would you like pictures updates of your pet while in our care?

Would you like extra information about your pet's care team?

Would you like to be discharged in the lobby, over the phone, or a private room?

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