Medical History Form Date MM slash DD slash YYYY Pet’s nameOwner’s nameMedical HistorySeizures? Yes No Heart problems? Yes No Allergic reactions? Yes No Drug allergies or reactions? Yes No If yes, what drug(s)?Diabetic? Yes No If yes, what type of insulin and units are given?Other serious or chronic medical issues? Yes No If yes, describeAny illness/trauma (vomiting/diarrhea, coughing, accident) in the past 30 days? Yes No Sedation HistorySedated previously? Yes No If yes, any problems?MedicationCurrently on medication(s) other than heartworm and flea/tick prevention? Yes No If yes, what medication?Heartworm prevention (dogs only)Current on heartworm prevention? Yes No If yes, what was the last date given?*If no, a heartworm test may be mandatory prior to anesthesia.Flea MedicationCurrent on flea medication? Yes No If yes, what brand and when was it last applied?Vaccination HistoryCurrent on vaccinations? If your pet is new to our hospital, please bring in vaccination records to your appointment. Yes No *If no, vaccinations may be required. Do you want vaccinations updated?Additional services Nail trim Microchip ($45, including lifetime registration) Express anal glands ($18 - $20) Other If otherYour pet will need to be fasted for their procedure. No food after 10 pm the night before, including no breakfast the morning of. Water is ok.I certify that all the information above is accurate to the best of my knowledge and that I have read and understand all the information above.Owner’s Digital SignatureCAPTCHA
