Internal Medicine Services

Owner Name: *

Pet's name *

Email: *

Phone Number: *

Date of last visit: *

Presenting Complaint *

Name of regular veterinary clinic: *

When was your pet last vaccinated? *

When was your pet last dewormed? *

If your pet has travelled outside Alberta, where and when? *

Does your pet live *
Indoors onlyIndoor/OutdoorOutdoors only

What other animals does your pet have contact with? Do they have health concerns? *

Does your pet have any allergies? If yes to what? *

Brand? *

Amount given in cups or cans? *

# of meals per day *

Treats *

Supplements *

Recent changes in diet? If so when and what was the previous food? *

Please list previous illnessess *

Please list any previous surgeries *

Please list all medications that your pet is currently taking or within the last week. (prescription and over the counter) *

Symptoms *
CoughingSneezingWheezingVomitingDiarrheaSeizuresLimpingAbnormal behaviourSkin masses or lumps notedOdor to breathTrouble BreathingFaintingLoss of BalanceRunny Nose/EyeScratchingChange in voiceLethargyTremorsWeaknessNone of the above

Explain symptoms *

My pet's energy level is: *

My pet's weight is: *

My pet's appetite is: *

The amount of water my pet is drinking is: *

The number of stools each day is: *

My pet's urination frequency is: *

Amount of urine passed each time is: *

Has the color of your pet's urine changed? *
YesNoUnsure

If Yes, what color? Any blood? Any Straining? *

Is your pet vomiting? *
YesNoUnsure

If Yes, is it Food, Water, Blood, or Foam? *

Does your pet have Diarrhea? *
YesNoUnsure

If Yes, is it bloody, black tarry, mucous foamy, large volume, small volume, associated with straining *

Does your pet historically have anal gland problems? *

Does your pet have or had previous skin conditions or ear problems? If so what treatments? *

Please list any questions or comments you have below. *

I authorize the staff at Trinity Hills 24 Hour Veterinary Hospital to use the following; Images and/or videos of my pet, my pets name/ medical conditions, on their social media platforms (Facebook, Instagram, and Tik Tok) *
YesNo