Medical History Form - Towne Square Animal Clinic

Owner's Name *

First

Last

Pet's Name *

Appointment Type *

In Clinic
Curbside

Best Phone Number

Best Email

I am in this vehicle

Any recent change in address, phone number(s) or email? *

Yes
No

If Yes, please list changes: *

Date of Appointment and Time *

Date

Time

Primary Reason for Appointment / Concern (please be as detailed as possible) *

Pet's Energy Level *

Normal
Increased
Decreased

If Increased or Decreased:

Please explain any changes in your pet's energy level, including when the change started and how significant it has been.

Pet's Appetite *

Normal
Increased
Decreased

If Increased or Decreased:

Please explain any changes in your pet's appetite, including when the change started and how significant it has been.

Food Brand *

Amount of food fed per feeding *

Recent bad breath or odd chewing? *

Yes
No

If Yes:

Please describe the bad breath or chewing behavior, including when you first noticed it.

Drinking / Water Intake *

Normal
Increased
Decreased

If Increased or Decreased:

Please explain any changes in your pet's water intake, including when you first noticed the change.

Recent persistent coughing? *

Yes
No

If Yes:

Please provide details, including how long the coughing has been occurring and how frequently it happens.

Recent persistent sneezing? *

Yes
No

If Yes:

Please provide details, including how long the sneezing has been occurring and how frequently it happens.

Recent persistent vomiting? *

Yes
No

If Yes:

Please provide details, including how long the vomiting has been occurring, how frequently it happens, and what the vomit looks like.

Has the pet had any recent persistent diarrhea or loose BM? *

Yes
No

If yes:

Please explain details, including duration, consistency, frequency, and any accidents.

Any current ear/eye concerns? *

Yes
No

If yes:

Please explain ear/eye concerns.

Any new skin concerns: lumps, bumps, or itchiness? *

Yes
No

If yes:

Please describe the concern and provide the approximate location of any lumps or bumps.

List any medications (prescription, prevention, supplements) your pet is currently taking:

Do you need refills of any of these medications (Including Heartworm preventative or Flea/Tick Control Rx - please be specific): *

Yes
No

If Yes:

Please list the specific medications you need refilled.

Do you need refills on any prescription pet food? *

Yes
No

If Yes:

Please list the prescription pet food you need refilled.