Examination Information Sheet
If any necessary treatments are recommended that pertain to my pet's problem today (please initial one)
_____ MVMC has my permission to perform them without further contact as long as the cost does not exceed $100.
_____MVMC has my permission to perform them without further contact not matter what the total cost will be.
Client Name___________________________________ Pet's Name________________________ Species______________Breed _____________Pet's Age__________
What are your pet's PRIMARY SYMPTOMS today?
________________________________________________________________________________________________________
When did you first notice the problem?_____________________________________________________________________
Has your pet: improved________ gotten worse_________ stayed the same_________
Is your pet: indoor only_________indoor/outdoor_________outdoor only________
Is he/she in contact with other animals? Yes________ No_________ If yes, are they healthy?________
Has there been any: coughing_________ sneezing________ vomiting________ diarrhea_________
Other symptoms the doctor should know about?___________________________________________________________
Water consumption has: increased________ decreased ________ stayed the same________
Urination has: increased________ decreased________ stayed the same________
Appetite has: increased_________decreased________ stayed the same_________
What is your pet's current diet? (please include all treats, etc.)
__________________________________________________________________________________________________________
Has there been any recent changes in your pet's diet or environment? (Please include any trips he/she may have taken or visitors to your house)
________________________________________________________________________________________________________________
Please list all medications he/she is currently receiving:
Heartworm preventative: Heartguard________ Interceptor________ Sentinel_________ Other_________
Flea preventative: Advantage_________ Frontline Topshot_________ Program_________ Other_________
Please list all other medications he/she is receiving including name, dosage, and administration frequency.
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