BluePearl North Carolina Medical History Form - BluePearl Pet Hospital Skip to the content

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Medical History Form

Pet's name*
Client's name*
Reason for today's visit*
Approximately when was your pet last seen by your primary care veterinarian?*
Is your pet currently being treated for any medical conditions?*
- Yes
- No
If yes, please describe*
Please list any medications or supplements your pet has received in the last two weeks. Include 1.) medication name 2.) dose 3.) frequency 4.) date/time of last dose*
Has your pet had any adverse reactions to medications, sedation or vaccinations?*
- Yes
- No
If yes, please describe*
Has your pet ever been diagnosed with heart disease or a heart murmur?*
- Yes
- No
Has your pet ever received a blood transfusion?*
- Yes
- No
Has your pet had any previous surgeries other than spay/neuter?*
- Yes
- No
If yes, please describe what and when*
Has your pet had any previous illness, injuries or been hospitalized?*
- Yes
- No
If yes, please describe what and when*
Has your pet been spayed or neutered?*
- Yes
- No
If your female pet has not been spayed, when was her last heat cycle?*
Has your pet ever been pregnant?*
- Yes
- No
Is your pet currently pregnant or nursing?*
- Yes
- No
Environment
What is your pet's primary living environment?*
- Indoor
- Outdoor
- Both
Is your pet housed with other animals?*
- Dogs
- Cats
- Other
If other, please provide details*
Is your pet housed with children?
- Yes
- No
If yes, how old are they?*
Has your pet traveled or lived outside of the state?
- Yes
- No
If yes, where?*
Diet
What does your pet normally eat? Select all that apply.*
- Canned
- Dry
- Homemade diet
- Other
What brand?*
How much?*
How often?*
Does your pet have food allergies?*
- Yes
- No
Preventatives
Is your pet up to date on vaccinations?*
- Yes
- No
- Unsure
Approximate date of last rabies vaccination*
Is your pet currently taking heartworm prevention?*
- Yes
- No
- Unsure
What brand?*
Is your pet currently taking flea and tick prevention?*
- Yes
- No
- Unsure
What brand?*
For cats, has your cat been tested for FeLV and FIV?*
- Yes
- No
- Unsure
What were the results?*
For dogs, has your dog been tested in the last 12 months for heartworm disease?*
- Yes
- No
- Unsure
What were the results?*
Behavior
Is there anything we should know about your pet’s behavior or temperament? (i.e., known to intentionally bite or scratch, has anxiety, needs to be muzzled for veterinary visits, etc.)*
Date*
MM slash DD slash YYYY