Patient Name:Client Name:Date of Appointment: Date Format: MM slash DD slash YYYY Doctor Name:Please list any past major surgeries or illnesses including date periods:Please list any current medications, including the dose and frequency of administration: Example: Prednisone 5 mg 1 tablet once daily in morningPet’s Diet:Does your pet go outside?YesNoWhen your pet goes outside is it:LeashPenLooseHas your pet traveled outside of New England?YesNoWhen was their travel?Where was their travel?Date of last Rabies vaccination (if known):Was it 3 year or 1 year?3 year1 yearPlease give us some information on your pet’s current medical or surgical problem:When did you first notice this: Weight Change Vomiting Diarrhea Constipation Drinking more water than normal Drinking less water than normal Eating more than normal Eating less than normal Sneezing or coughing Change in behavior Gagging or regurgitation Skin or ear problems Lethargy (quiet, withdrawn) Painful Masses or lumps Blood in stool Blood in urine Other Please describeDoes your pet have any known allergies:YesNoPlease list known allergiesHas your pet had any adverse reactions to medications and/or anesthesia?YesNoPlease list adverse reactions to medications and/or anethesiaPlease list any special concerns you may have: