Pre-Visit Medical Form Owner name* First Last Phone*Today's Date* MM slash DD slash YYYY Pet's Name*Please describe the current problem with your pet.*How long has this been going on?*How has your pet been eating?*What kind of food and how much does your pet normally eat?*How has your pet been drinking?*Has there been any vomiting? If yes, how often, for what duration? What is the consistency/nature of the material vomited up?*Has there been any diarrhea? If yes, how often is it occurring? What is the consistency of the diarrhea? Have you noticed any blood or black, tarry material?*Has your pet been urinating more or less than normal? Does your pet appear painful when urinating? Have you noticed any changes to the appearance of the urine?*Is your pet taking prescription medications or supplements? Have you given your pet any over-the-counter medications recently?*Are you currently giving your pet heartworm and flea and tick preventatives?* Yes No Does your pet have any chronic health issues?*If your pet is a cat, does your cat go outside, even intermittently? Yes No Has your pet been exposed to anything abnormal such as non-prescribed medications, new foods, garbage, etc?* Yes No If Crosslake Veterinary Hospital is not your primary care veterinarian, who is your regular veterinarian and may we request medical records?