East Valley Animal Clinic / Medical History Form

East Valley Animal Clinic

5049 Upper 141st Street West
Apple Valley, MN 55124

(952)423-6800

www.eastvalleyanimalclinic.com

Medical History form

Name (required)
First Name (required)
Last Name (required)
Phone (required)
Phone TypePhone Number (required)
Pets Name (required)

Pets Information
Primary Concern(s) (length and duration of problem (required)

Previous and Current Diet (amount fed and how often) (required)

Current Medications/Supplements (Prescribed and over the counter) (required)

Time Medications/Supplements were given/ How much and how often being given (required)

Any coughing/sneezing/vomiting/diarrhea (for how long?) (required)

Stiffness/Soreness/New Lumps or Bumps (Where?) (required)

Scratching/Licking (Where?) (required)

Any changes in Environment/Household (required)


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