At Safe Haven Veterinary Hospital, our mission is clear: Your Pet is Our Pet. Click here for a PDF version INTERNAL MEDICINE PATIENT SHEET: Patient Name:(Required) First Last Your Name:(Required) First Last Email(Required) Today's Date:(Required) MM slash DD slash YYYY If feline: Indoor Outdoor Indoor & Outdoor What are your concerns about your pet?(Required) Please list any additional household pets:(Required) Pet's current diet:(Required) When was your pet last vaccinated?(Required) Have you traveled with your pet recently? If so, where?(Required) List any flea/tick/heartworm preventative:(Required) Please outline additional medical history, including surgeries, allergies, and special needs:(Required) Current Medications:Medication: Dosage/Frequency: Pet's Response: Medication: Dosage/Frequency: Pet's Response: Medication: Dosage/Frequency: Pet's Response: Medication: Dosage/Frequency: Pet's Response: Discontinued or Completed Medications:Medication: Dosage/Frequency: Pet's Response: Medication: Dosage/Frequency: Pet's Response: Medication: Dosage/Frequency: Pet's Response: Has your pet exhibited any of the following?Lethargy:(Required) Yes No If yes, duration: Change in water consumtion:(Required) Yes No If yes, duration: If yes, increase or decrease? Change in urination:(Required) Yes No If yes, duration: If yes, increase or decrease? If yes, is there straining or blood? Change in appetite:(Required) Yes No If yes, duration: If yes, increase or decrease? If decrease, are they interested in eating? If decrease, is there oral pain? Vomiting:(Required) Yes No If yes, duration: If yes, active or passive? If yes, is it food OR bile/saliva? Diarrhea:(Required) Yes No If yes, duration: If yes, is there blood and/or mucus? If yes, is there straining? If yes, is there abnormal stool color? Describe if so. If yes, is stool watery? If yes, is there a sense of urgency? Constipation:(Required) Yes No If yes, duration: Weight Loss:(Required) Yes No If yes, over what time period? If yes, has the pet's appetite increased, decreased, or is unchanged? Gagging/retcheing:(Required) Yes No If yes, duration: Coughing:(Required) Yes No Sneezing:(Required) Yes No Abnormal breathing:(Required) Yes No If yes, please describe: If yes, is it associated with activity or excitement? Other: EmailThis field is for validation purposes and should be left unchanged. Δ