Other Medical History

If your pet has medical history from another veterinary facility, please have them email us the records to records.myanimalcarecenter@gmail.com

Pet Name *

Your Name *

First

Last

Email *

Phone *

Have you, someone in your home, or your pet experienced respiratory symptoms (coughing, sneezing, wheezing, or fever) in the last 14 days? *

Yes
No

Have you or someone in your home been asked by a healthcare professional and/or the Department of Health/CDC to quarantine in the last 14 days? *

Yes
No

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Reason for your pet's visit today? *

This issue began on *

This issue is: *

Has your pet had any:

Other

My pet's appetite is: *

My pet's thirst level is *

My pet's activity level is: *

My pet's urination is: *

My pet eats *

Other

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Brand of Pet Food *

How Often Is Your Pet Fed? *

If prescription diet, what formulation?

How Much Is Your Pet Fed PER MEAL? *

In addition to pet food, what treats or other food does your pet receive? (Include any human food, veterinary dental products, bones, rawhides, etc.)

Has your pet's diet changed in the last 6 months? *

Yes
No
I am not sure

Is it possible for your pet to have *

Eaten garbage
Ingested Mushrooms
Eaten toys (part of toys missing, chewed up, etc.)
Ingested human or animal medications not intended for them or at higher doses than intended?
Ingested toxins (rat bait, ant bait, other known toxic substances)
Ingested Marijuana
Eaten grain free diet for any period of time
None of the above

Please list any medications, supplements, or topical treatments your pet has received in the past month and when they were last given:

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When Was Your Pet's Last Dose of Heartworm Preventative? *

Date Given (Please type N/A if not on a preventative)

When Was Your Pet's Last Dose of Flea/Tick Preventative? *

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use? *

Name of medication - put unknown if not sure

What Kind of Heartworm Preventative Do You Use? *

Name of medication - put unknown if not sure

Is Your Pet *

Other

Are There Other Pets In The Home

Yes
No

Does Your Pet *

Is Your Pet Current On Vaccinations? *

Yes
No
I am not sure

My pet's vaccines were administered last by:

At Animal Care Center and Pet Resort
I Am Not Sure Where
Other

Other

Does Your Pet Have A Microchip?

Yes
No
I am not sure

Does Your Pet Have Known Health Concerns and/or Chronic Diseases or Conditions?

If yes, please tell us more. If no, please note N/A.

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A.

Are there pictures or videos that would help us with our exam today?

Click or drag a file to this area to upload.

Is There Anything Else You Would Like To Discuss Today?

Name *

Pre History Question Form

Pre History Question Form

Other Medical History

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