Patient History Form Patient History Form Location * Select LocationAnnapolisHunt ValleyColumbia Name * Name First First Last Last Email * Patient Name * Species * Dog Cat Sex * M F Where did you get your pet? * What diet does your pet eat? * How much does your pet eat? * When did your pet last eat? * How much water do you think your pet drinks? * Normal AmountMore Than NormalLess Than Normal Is your pet spayed/neutered? * Yes No How old were they at the time of surgery? * Is your pet kept primarily * IndoorsOutdoorsBoth If your pet goes outdoors, is access limited to an enclosed area? * For Dogs Has your dog been checked for heartworm this year? * Yes No If your dog is on a preventative, please list it here Please check the vaccines your dog has received Distemper (in the last year) Rabies (in the last 3 years) Lyme (in the last year) Distemper Vaccine Received on Rabies Vaccine Received on Lyme Vaccine Received on For Cats Has your cat been tested for feline leukemia or feline immunodeficiency virus? * Yes No When was the test and what were the results? Please check the vaccines your cat has received Distemper/Upper Respiratory (in the last year) Rabies (in the last 3 years) Feline Leukemia (in the last year) Distemper/Upper Respiratory Vaccine Received on Rabies Vaccine Received on Feline Leukemia Vaccine Received on If your pet is on any medications, please list the name, strength, and amount given below: Please include prescriptions, non-prescriptions, and nutritional supplements. If your pet has had any adverse reactions to medications, please list them here Please list any additional pets you have in the household: Please list any known illnesses affecting your other pets If your pet has ever lived or traveled extensively outside of the Maryland/Virginia/DC area, please list when, where, and for how long Please list any past surgical or medical history I grant AVIM&O, its representatives and employees the right to take photographs of my pet and me. I authorize AVIM&O, its assigns and transferees to copyright, use and publish the same in print and/or electronically. * Yes No Submit If you are human, leave this field blank.
