AVSG Nephrology Medical History Form

Primary Owner (responsible for medical and financial decisions) *

First Name

Last Name

Pet's Name *

First Name

Last Name

Primary Care Veterinarian

First Name

Last Name

Primary Care Animal Hospital Name

Please list all other hospitals the pet has seen previously (including other ER/Specialists)

Reason for consultation *

Describe when your pet's kidney and/or urogenital disease was first diagnosed

Does your pet have any past pertinent medical history (not related to the presenting problem)? *

YesNo

If yes to the above, please describe

How long have you had your pet in years and months? *

Are there other pets are in the house? *

CatsDogsOtherNone

Is your pet indoor or outdoor? *

IndoorOutdoorBoth

Has your pet ever traveled outside the Orange County area? *

YesNo

If yes, indicate the location traveled to and date/year or frequency

Is your pet up to date on their vaccination protocol? *

YesNo

Is your pet up to date on parasite preventative medication? *

YesNo

Name of primary food offered *

Indicate formulation offered *

CannedDry

Indicate amount fed per day in cups or cans (ex: 1 cup dry or 2 cups canned) *

Do you feed your pet human food/table scraps? *

YesNo

Estimate what percentage of your pet's food is human food

Do you feed your pet any treats or other foods not listed above? *

YesNo

If yes to the above, please provide details

Estimate what percentage of your pet's food is treats

Has your pet's appetite been normal? Abnormalities may include decreased appetite (eating less than prior), appearing more "picky" and having to change the diet to keep the pet interested) or increased appetite *

YesNo

If no to the above, please provide details

When did your pet last eat? *

This morningThis afternoonLast nightLonger than 24 hours ago

Does your pet have access to nephrotoxins (human medications [e.g. non-steroidal anti-inflammatory medications such as Advil or Aleve, Tylenol, antibiotics, chemotherapeutics], grapes/raisins, ethylene glycol [Anti-freeze], herbicides/pesticides, vitamin-D containing rodenticides or supplements, mushrooms, lilies for cats)? *

YesNo

List all medication or supplements given in the last 6 months. Please be as specific as possible, including name of medication, strength/dosage, how it's given, how often it's given, date medication was started, and last time administered. *

Is your pet's water intake normal? Abnormalities may include increased or decreased thirst *

YesNo

If no to the above, please provide details

Are your pet's urination habits normal? Abnormalities may include increased urination volume and frequency, more frequent urination with small urination volume, straining to urinate, blood in the urine, pain while urinating, urinating outside of the litter box (for cats) *

YesNo

If no to the above, please provide details

Are your pet's bowel movements normal? *

If no to the above, describe them by checking all options that apply

When did the abnormal bowel movements start?

How often is your pet having adnormal bowel movements?

Has your pet been vomiting *

YesNo

When did the vomiting start? *

How often is your pet vomiting?

Has your pet exhibited any signs of nausea (e.g. drooling, lip licking, exaggerated swallowing, appearing eager to eat and then smelling the food and becoming uninterested)? *

YesNo

If yes to the above, please provide details

Is your pet's energy level normal? *

YesNo

If no to the above, please provide details

Has your pet's weight been stable? Abnormalities may include weight gain or weight loss. *

YesNo

If no to the above, please provide details

Is there coughing or sneezing, or any other abnormal signs? *

YesNo

If yes to the above, please provide details

What is your goal with this visit? *

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

Please type your name as your signature *

Our partner hospital

Veterinary Surgical Specialists

2937 Edinger Ave
Tustin, CA 92780
949-936-0055
M-F 7:00am - 6:00pm, weekends 8:00am - 6:00pm

Our partner hospital

Veterinary Surgical Specialists

2937 Edinger Ave
Tustin, CA 92780
949-936-0055
M-F 7:00am - 6:00pm, weekends 8:00am - 6:00pm

Pet Medical History for Nephrology Consultation

AVSG Internal Medicine Emergency & Critical Care

Our partner hospital

Veterinary Surgical Specialists

Our partner hospital

Veterinary Surgical Specialists