Veterinary History Form

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(For referred cases, to be completed by referring DVM prior to consultation)

Contact Information

Clinic:

Phone number:

Address:

Postal Code:

Referring veterinarian:

Preferred email for contact

Fax number:

Client name:

Pet's name:

Behavioral History

Describe the pet's behavior in your clinic, including any problems that you have observed:

For what behavior problems is this dog being referred? (i.e., presenting complaint or diagnosis)

Please indicate any advice or counseling that you have given the client thus far (including dates):

Have any medications or products been suggested? If yes, indicate dosage, dates, duration, and response:

Medical History

Date of most recent physical/dental examination:

List any abnormal findings:

Vaccine status:

Date:

Vaccines administered:

List any present medical problems:

Are you aware of any sensory deficits?

YesNo

If yes, describe:

Are you aware of any painful conditions in the pet?

YesNo

If yes, describe:

List any previous medical problems:

Is the pet presently receiving treatment or medication of any type? If prescribing a drug, include name and dose.

Diagnostic Screening Tests

Attach a copy of all recent diagnostic or screening tests below. Alternatively, please complete this section.

Any recent diagnostic screening:

Indicate what diagnostic or screening tests have been performed and the date of each:

List any abnormal results: