Silver Maple Vet Clinic: Med History Form

	Comprehensive Patient Medical History Form (Page 3 of 3) [1] [2] [3]
	Silver Maple Veterinary Clinic, Inc. 14993 Kutztown Road, Kutztown PA 19530 610-683-7988
Thank you for taking the time to complete this form. We appreciate the opportunity to take care of your pet's health needs.

Please fill out this form and bring it to your appointment.

	YES	NO
Is your address and phone number still correct?
Do you have pet health insurance?
Are your pets vaccinations up to date?
Is your pet spayed or neutered?
Was there a heartworm test in the last year?
Is your pet taking heartworm prevention Rx?
Has your pet been tested for worms in the last year?
Have you seen your pet passing worms?
Has your pet had any illness/injury in the last year?
Has your pet ever had a seizure?
Does your pet get table scraps?
Did your pet eat in the last four hours?
Does your pet ever strain to urinate?
Has there been any recent vomiting?
Has your pet been coughing?
Has your pet been sneezing?
Has your pet been gagging?
Any listlessness?
Any weakness?
Any lameness? Which Leg?:
Shaking of the head?
Scratching? Where?
Significant hair loss?
Scooting of the rear?
Unusual lumps or bumps?
Bad breath?
Unusual discharge?
Diarrhea?
Constipation?
Stiffness?
Behavioral changes?

Reason for Today's Visit

Has your pet been examined elsewhere for the same condition? Yes:

If so, Where?

What medications is your pet taking now?

Is your pet allergic to any foods or Rx? Yes:

If yes, please briefly describe:

What flea control is used?

Anything else we should know?

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