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Internal Medicine History Form

Internal Medicine History Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 434-202-2987 for a faster response.

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Client's Name(Required)

First Last

Email(Required)

Patient Name(Required)

What is the primary reason your pet is seeing an internal medicine doctor?(Required)

When did you start noticing the symptoms?(Required)

Has your pet been evaluated for this problem before?(Required)

Yes

Which diagnostics were performed?(Required)

Which medications were administered and for how long?(Required)

How did your pet respond to the treatment?(Required)

Has your pet’s general activity level(Required)

Increased

Decreased

Remained Normal

If increased or decreased, for how long?(Required)

Has your pet’s water intake been(Required)

Increased

Decreased

Remained Normal

If increased or decreased, for how long?(Required)

Has your pet’s appetite been(Required)

Increased

Decreased

Remained Normal

If increased or decreased, for how long?(Required)

Does your pet’s diet consist of(Required)

Commercial Food

Prescription Food

Table Scraps

Other

Please list food(s)(Required)

When did your pet last eat?(Required)

Have you noticed any changes in your pet’s urination behavior or frequency?(Required)

Yes

Please describe changes(Required)

Have you noticed any:

Coughing?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Sneezing?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Vomiting?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Coughing?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Diarrhea?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Abnormal Urine?(Required)

Yes

Duration?(Required)

Frequency?(Required)

Triggers?(Required)

Any abnormal discharge from ears, eyes, nose, mouth, rectum, genitals?(Required)

Yes

Please describe location, any characteristics, duration(Required)

Has your pet traveled out of the state of Virginia within the past year?(Required)

Yes

If yes, when, and where?(Required)

Are your pet vaccines current and within the last 12 months?(Required)

Yes

Year of last rabies vaccine(Required)

Has your pet been vaccinated with any elective vaccines (such as leptospirosis, Lyme, FeLV and/or FIV) within the past 12 months?(Required)

Yes

Unknown

If yes, when?(Required)

Please describe all medications, including heartworm and flea/tick prevention that your pet is taking:

Medication Name, Strength, Amount Given, Frequency, Last Given (Date, Time), Duration Prescribed

If medications are to be dispensed, does your pet prefer(Required)

Pill

Liquid

Other

If other, please specify(Required)

Has your pet ever experienced adverse or allergic reactions to any medication?(Required)

Yes

If yes, please describe(Required)

Does your pet have any known food allergies?(Required)

Yes

If yes, which foods?(Required)

Has your pet had any significant injuries, illness, surgery, or medical problems in the past that are not covered by the previous questions?(Required)

Number of other pets in the household(Required)

Is your pet and his/her housemates(Required)

Indoor Only

Outdoor Only

Both

Are any other pets showing the same symptoms as your pet visiting today?(Required)

Yes

We proudly serve the pets of

Charlottesville, VA. and beyond.

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and specialized veterinary care from your pet's first adventure throughout a long and healthy life.

Get In Touch

Our team is here to help.



Email

info@vavetspecialists.com



address

370 Greenbrier Dr. Charlottesville, VA. 22901

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Phone

434-202-2987

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Hours

Mon - Fri :
7:00am – 6:00pm

Sat - Sun : Closed

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