Veterinary Village LLC Information for your visit for your sick or injured pet Your Name Pet’s Name Email Phone Numbers Home Cell Work HISTORY Lifestyle - None -IndoorOutdoor Family - None -PetPerformance DogBreeding DogService Dog Travel? Boarding? Dog Events? Diet: Main diet Amount and frequency of feedings? Treats/snacks Any change to diet in the last month? Allergies to food, medications, or vaccinations? Current Medications (please include prescriptions, over-the-counter drugs, and any supplements used within the past month) Are there records from another veterinary clinic that we should be aware of? If so, please provide name of veterinary clinic as well as phone number, and any other names the pet may be listed under. SYMPTOMS When was your pet last normal? What symptoms appeared first, and when did they appear? Are symptoms improving, worsening, or staying the same since then? Has your pet been treated for a similar condition previously? Describe medications/response PLEASE NOTE ANY SPECIFIC PROBLEMS NOTICED IN THE FOLLOWING BODY SYSTEMS/CATEGORIES General Activity Level? Weight Change? Mobility/Musculoskeletal/Joints? Appetite? Thirst/Urination? Vomiting/Diarrhea? Coughing/Sneezing/Breathing Changes? Eyes? Ears? Skin? Behavior? Reproductive Organs?
