History Form CLIENTPATIENT:Name*MEDICAL HISTORY: Drug consultation* Yes No Lifestyle* Indoor Outdoor Both Attitude* Bright/Alert/Responsive Quiet/Depressed Appetite* Normal Increased Decreased Drinking* Normal Increased Decreased Diet(Brand, Flavor, Amount Fed):*Treats/Supplements*Dental Hygiene* Dental Chews Brushing Teeth None Medications* Defecation* Normal Abnormal If Abnormal, explain*Urination* Normal Abnormal If Abnormal:, explain*Vomiting* Yes No Coughing* Yes No Sneezing* Yes No Allergies*Limping/Lameness*Masses*Heartworm Prevention* Oral Injectable None Flea/Tick Prevention* Oral Topical None Microchip* Yes No Would you like a nail trim today?* Yes No Behavioral Issues*Why are you here with your pet today?*How long has this been going on?*Has it gotten* Better Worse Stayed the Same N/A Pain Score* 0 1 2 3 4 5 6 7 8 9 10 N/A Other Concerns*
