8650 W. Tropicana Avenue, Ste. B-107, Las Vegas, NV 89147

Reopening Soon!
North Rainbow Veterinary Emergency Hospital
4445 North Rainbow Blvd, Craig & Rainbow, Las Vegas, NV 89108

Phone: 702-871-1152

Home
For Pet Owners
for Veterinarians
Prescription Refills
Online Payments
Contact Us

for Veterinarians

Prescription Refills

Online Payments

Internal Medicine – Recheck Patient Medical History Questionnaire

Internal Medicine – Recheck Patient Medical History Questionnaire

Thank you for taking the time to completely fill out the following questionnaire. This form is filled out at every visit to make sure that we have the most recent and accurate information.
Client Name
Pet's Name
Phone
Date
MM slash DD slash YYYY
Please list all the primary vet clinics your pet has seen:
When was your pet’s last visit with the primary Veterinarian?
Hidden
Best Contact Number for Today:
Wt (kg)
Temperature
HR
RR
BP
CRT/MM
What is your primary concern about your pet today?
Was food withheld for today's visit?
- Yes
- No
Last fed at what time/date?
Do you see improvement from the last visit?
Activity Level
Appetite
Water Consumption
Urination Frequency
Bowel Movement
Diarrhea
- Yes
- No
If yes....describe
Vomiting
- Yes
- No
If yes....describe
Respiratory
- Sneezing or Nasal/Ocular Discharge
- Coughing
- Difficulty Breathing
Describe:
Frequency/Describe:
Describe:
Pain
- Yes
- No
Describe
New Lumps/Bumps:
- New Lumps/Bumps:
- Added new treats
- Unintentional changes (trash/plants/other)
(trash/plants/other)
Dietary Changes: Please Describe:
Medications, Vitamins, or Supplements your pet is currently receiving at home:
Name
Strength (mg)
# of tab/caps
Frequency Given
Last Given
Refill? Y | N
- Yes
- No
Please check or click here to add more
- Add More
Name
Strength (mg)
# of tab/caps
Frequency Given
Last Given
Refill? Y | N
- Yes
- No
Please check or click here to add more
- Add More
Name
Strength (mg)
# of tab/caps
Frequency Given
Last Given
Refill? Y | N
- Yes
- No
Previous Medications:
Diet History Continued:
If applicable, would you like a copy of today’s bloodwork results?
- Yes
- No
CAPTCHA

Las Vegas Veterinary Specialty Center Copyright © 2023.

Care Credit

Las Vegas Veterinary Specialty Center | 8650 W. Tropicana Avenue, Ste. B-107 | Las Vegas, NV 89147
Phone: 702-871-1152, Fax: 702-262-7000
Copyright 2015 Las Vegas Veterinary Specialty Center - Las Vegas Veterinarians.

Copyright (c) Las Vegas Veterinary Specialty Center 2013. All text, images, photographs and other materials contained or displayed on this site are wholly owned by and are proprietary to Las Vegas Veterinary Specialty Center and constitute valuable intellectual property. No materials from any part of this site are authorized or intended to be downloaded, transmitted, broadcast, reproduced or in any other way used or otherwise disseminated in any form to any person or entity, unless said person or entity has an express, prior written license to do so. All unauthorized duplication or any other use of materials from this site shall constitute intentional infringement(s) of Las Vegas Veterinary Specialty Center intellectual property and shall further constitute a violation of our trademarks, copyrights, and other rights. Without further notice we will prosecute to the fullest extent allowed by civil and criminal law.

Website by DOCTOR Multimedia

Sitemap | Accessibility

Font Resize

Contrast

Accessibility by WAH