Illness History Form Illness History Form Owner's Name * Owner's Name First First Last Last Pet's Name * Best Phone Number * What symptoms are you seeing in your pet? * Are the symptoms the same, better or worse now? * How long has your pet been showing these symptoms? * Any weight loss or weight gain? * Have you noticed appetite changes? * Any changes in behavior? * Vomiting or diarrhea? * Is your pet in pain? * Is your pet currently taking any medications, including over the counter medications or supplements? * When were the medications last given? * Has there been any inappropriate urination or defecation? * Are there specific areas your pet has been urinating or defecating? * Are you currently using any heartworm, and/or flea and tick prevention? * How much do you have on hand? * Have you seen any fleas or ticks on your pet? * Is your pet due for any vaccines you would like to update today? * If you are human, leave this field blank. Next
