Veterinary Referral - Veterinary Behavior Specialties

VETERINARY HISTORY FORM

Clinic
Address
Street Address City State ZIP Code
Client's name*
Phone #
Doctor's name
Postal code
Fax#
Pet's name
Behavioral History
Describe the pet's behavior in your clinic, including any problems that you have observed
For what behavior problem is this dog being referred? (i.e., presenting complaint or a.agnosis)
Please indicate any advice or counseling that you have given the client thus far (including dates)
Have any medications or products been suggested? If yes, indicate dates, duration, and response
Medical History
Date of most recent physicaVdental examination
List any abnormal findings
Vaccination status
Date
Vaccines administered
List any present medical problems
Are you aware of any sensory deficits?
- Yes
- No
If yes, describe
Are you aware of any painful conditions in this pet?
- Yes
- No
If yes, describe
List any recurrent or previous medical problems
Is the pet presently receiving treatment or medication of any type?
Diagnostic Screening Tests
Attach a copy of all recent diagnostic or screening tests. Alternatively, please complete this section.
Indicate what diagnostic or screening tests have been performed and the date of each
List any abnormal results