INTERNAL MEDICINE: PET Medical History All fields labeled with an asterisk (*) are required. Primary owner (responsible for medical and financial decisions)*Pet's Name*Medical HistoryPlease include as much detail as you are able. We will make every reasonable attempt to obtain your pet's previous medical records and/ or imaging from previous facilities you have taken your pet to, so please be sure to list hospital details.Reason for consultation*Primary concern and duration of current problem*How would you characterize your pet's temperament?* Friendly Nervous Has your pet traveled outside of Southern California recently?* Yes No If yes, where and when?*Has your pet seen any other specialist(s)?* Yes No If yes, please select from the following options (mark all that apply)* Cardiology Dentistry Dermatology Internal Medicine Neurology Oncology Ophthalmology Surgery Imaging (CT/ MRI) Please list any and all other hospitals/ veterinary offices that have treated your pet for anything in the past 6 months.*Has your pet had bloodwork in the last 6 months?* Yes No If yes, where and when?*Has your pet had x-rays in the last 6 months?* Yes No If yes, where and when?*Has your pet had an abdominal ultrasound in the last 6 months?* Yes No If yes, where and when?*Has your pet had an echocardiogram in the last 6 months?* Yes No If yes, where and when?*Does your pet have a history of seizures?* Yes No Date of last seizure Month Day Year Does your pet currently receive any medications?* Yes No If yes, please provide a detailed list of medications (include strength, dosage, and frequency of administration):*Does your pet currently receive any supplements?* Yes No If yes, please provide a detailed list of supplements (include strength, dosage, and frequency of administration):*Has your pet had any drug reactions/allergies?* Yes No If yes, please describe:*Is your pet currently on any of the following? (mark all that apply)* Flea Medications Tick Medications Heartworn Medications None What diet is your pet currently on? (include brand, amount offered, and frequency)*What treats/ snacks/ human food does your pet receive? (include brand, amount offered, and frequency).*Has your pet had any food allergies?* Yes No If yes, please describe:*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
