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Medical History Form

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Complete your medical history form online!

Your Name *

First

Last

Pet's Name *

Species *

Breed *

Sex *

Female
Male

Fixed *

Yes
No

Email *

Single Reason for Visit *

Excessive Thirst? *

Yes
No

How Long has This Been Happening? *

Discharge from Eyes? *

Yes
No

How Long has This Been Happening? *

Squinting eyes? *

Yes
No

How long has this been happening? *

Has your Pet Been to the Lower 48? *

Yes
No

When? *

Was Pet on Preventatives? *

Yes
No

Does your Pet Have Diarrhea? *

Yes
No

What Kind of Diarrhea? *

Liquid
Soft
Bloody

How Long? *

How Often? (copy) *

Is Your Pet Vomiting? *

Yes
No

What Kind of Vomit?

Food
Water
Bile
Other

How Long? *

How Often? *

Does Your Pet Have Excessive Drooling? *

Yes
No

How Long? *

Does Your Pet Have Foul Breath? *

Yes
No

How Long? *

Is Your Pet Experiencing Lame Liming? *

Yes
No

How Long? *

Is Your Pet Lethargic? *

Yes
No

How Long? *

Does Your Pet Have Difficulty Urinating? *

Yes
No

How Long? *

Has Your Pet Experienced Weight Gain/Loss? *

Yes
No

How Long? *

Is Your Pet Eating/Drinking Well? *

Yes
No

How Long? *

Is Your Pet Experiencing Excessive Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Poor Balance? *

Yes
No

How Long? *

Is Your Pet Experiencing Pain? *

Yes
No

How Long? *

Has There Been Change in Urine? (Color/Odor) *

Yes
No

How Long? *

Has There New or Unusual Lumps? *

Yes
No

Where? *

How Long? *

Are There Any Wounds? *

Yes
No

Where? *

When Did it Happen? *

Has your Pet Experienced Inappropriate Urination? *

Yes
No

How Long? *

Is Your Pet Experiencing Balding/Losing Hair? *

Yes
No

How Long? *

Where? *

Is Your Pet Experiencing Excessive Panting? *

Yes
No

How Long? *

Does Your Pet Have Dirty/Smelly Ears? *

Yes
No

How Long? *

Is Your Pet Experiencing Sneezing/Coughing/Hacking? *

Yes
No

How Long? *

Is Your Pet Experiencing Labored Breathing/Wheezing? *

Yes
No

How Long? *

Is Your Pet Scratching Ears/Shaking Head? *

Yes
No

How Long? *

Is Your Pet Current on Rabies? *

Yes
No

*Must be able to provide proof today.

Additional Information You Feel We Should Know

Health Certificate

Are you being seen for a "Travel Certificate" or "Health Certificate" to drive across the boarder or to fly on a plane? *

Yes
No

Alaska Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Destination Address *

Address Line 1

Address Line 2

City

State

Zip Code

Transportation *

Flying
Driving
Ferry
Train

Travel Purpose *

Vacationing
Moving

Are You Traveling with Your Pet? *

Yes
No

Repeat Your Name *

First

Last

Your Phone *

Person Dropping Pet Off at Airport Name *

First

Last

Person Dropping Pet Off at Airport Phone *

Are you interested in Anxiety medication today? *

Yes
No

Are you interested in Flea/Tick/Heartworm preventatives today? *

Yes
No

Has your pet been to the lower 48 before? *

Yes
No

Current Medications and Supplements

Current Medications/Herbal Supplements

Other

Recent Emergency Visits? Where Was Your Pet Seen?

Primary Contact Today (Name) *

Primary Phone Today *

Signature *

Date *

Have you or your pets been seen at Chester Valley Veterinary Hospital within the last 2 years?

Yes

No

We are not currently seeing New Clients for Wellness. However, if your pet is sick please see our Urgent Care Walk Ins option.

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