Medical History Form – Minden Animal Hospital

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Medical History Form

Please complete this form prior to your appointment.

Name*
First Last
Phone*
Email*
Pet's Name*
Main Concern (please describe):*
Any history of vaccine reactions?*
- Yes
- No
If Yes, please describe:
Any coughing or sneezing?*
- Yes
- No
If Yes, please describe:
Any vomiting or diarrhea?*
- Yes
- No
If Yes, please describe:
Any limping?*
- Yes
- No
If Yes, please describe:
Any lumps?*
- Yes
- No
If Yes, please describe:
Any discharge from nose or eyes or ears?*
- Yes
- No
If Yes, please describe:
Any changes in activity levels?*
- Yes
- No
If Yes, please describe:
Any change in appetite?*
- Yes
- No
If Yes, please describe:
Any change in drinking or urination?*
- Yes
- No
If Yes, please describe:
How are your pet’s bowel movements?*
- Normal
- Abnormal
If abnormal, please describe:
What is your pet’s current Diet? (please describe):*
How many cups of food do you feed per day? (please describe):*
What treats or additional foods do they get? (please describe):*
Is your pet on any medications currently?*
- Yes
- No
If Yes, please describe:
Is your pet on any supplements currently?*
- Yes
- No
If Yes, please describe:
Is your pet on any parasite prevention (flea/ tick/ heartworm) at any time during the year?*
- Yes
- No
If Yes, please describe:
Does your pet have any travel history outside of the Haliburton County?*
- Yes
- No
If Yes, please describe:
Do you have any other pets at home?*
- Yes
- No
If Yes, please describe:
Where does your pet spend time?*
- Indoors
- Outdoors
- Both

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