Alternative Care Medical History Form

Pet Name*

Date of Birth/Age*

Species*

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Breed*

How long has pet been with you?

Cat indoor or outdoor?

Indoor

Outdoor

Other pets in home?

Brief explanation in one sentence explaining pet’s problem:

Thirst

Normal

Increased

Decreased

Excessive

Thirstless

Appetite

Normal

Ravenous

Finicky

Poor/Decreased

Not eating at all

Number of times fed daily:

Dry Brand:

Canned Brand:

Homemade? Ingredients?

Supplements:

Treats:

Weight

Normal

Overweight

Obese

Underweight

Emaciated

Gums/Teeth

Inflamed Gums

Bleeding Ulcers

Tartar

Odor

Missing Teeth

No Teeth

Broken Teeth

Vomiting

Never

Yes

If yes, please describe:
How often - daily, weekly, monthly, or yearly?
What do they vomit? (Phlegm Bile Food)
When? (Seconds to minutes after eating/ Hours later/ Intermittently)

Diarrhea

Never

Yes

If yes, how often?

Daily

Weekly

Monthly

Yearly

Stool Consistency

Formed

Semi-formed

Toothpaste

Pudding

Watery

Other

Color of Stool

Brown

Light

Medium

Dark

Blood

Other

How many times a day?

Can you describe the odor?

Constipation

Semi-dry

Crumble

Dry

Rock hard

Soft

Straining?

Enemas
How often?

Urination
Color

Yellow

Orange

Bloody

Brown

Pale

Any odor?

Crystals seen?

Straining?

Frequency? Increased, normal, decreased

Vocalizing?

Yes

No

Accidents in house?

Yes

No

If yes, where?

Involuntary Incontinent?

Dribbling urine involuntarily

Bladder stones?
What type? ( Many, Few, Big, Small)

Surgery: Bladder Kidney Urethral

Male cats: blocked? How many # times?

Catheterized?

Yes

No

Surgery on urethra?

Yes

No

What age?

Relapses since surgery?

Eyes
Discharge?

Crusty

Thick

Thin

Burning skin

Mucoid

Other

Color?

Clear

Yellow

Green

Gray

Black

Brown

Blood

Other

When?

Daily

Occasionally

None

Vision?

Decreased

Normal

Which eye?

Both

Left

Right

Nose
Discharge?

Crusty

Thick

Thin

Burning skin

Mucoid

Other

Color?

Clear

Yellow

Green

Gray

Black

Brown

Blood

Other

When?

Daily

Occasionally

None

Sneezing?

Yes

No

Odor to discharge?

Which side?

Both

Right

Left

Ears
Discharge?

Clear

Yellow

Green

Gray

Black

Brown

Blood

Other

When?

Daily

Weekly

Monthly

Yearly

Seasonally

Other

Itchy?

Yes

No

Swollen Painful Ulcerated Bleeding Ear problems?

Yes

No

Ear mites in past?

Yes

No

Odor?

When started what age?

Ear problems presently?

For how long?

Cleaning? How often? Product used Other medicines used

Ear flushes done? How often

Past Hematomas?

Yes

No

Which ear?

Both

Right

Left

Nervous System
Seizures?

Never

Yes

How often?

Age they began?

Known trigger?

History of head injury?

Body during a seizure? (ex: Stands, Lies sternal, Lies on the side, Legs stiff, Front Back Shaking Entire body Legs only Head bobbing Jaw chomping)

Behavior before seizure?

Drooling

Clingy

Aloof

Indifferent

Aggressive

Other

Urinates with seizure? When?

Defecates with seizure? When?

How long does it take to recover from a seizure? (Seconds Minutes Hours Days)

Afterwards?

Exhausted

Acts normal

Disoriented

Sleeps

Skin
Itchy? Started when?

Where?

Self mutilates Scratches with feet Where?

Bites or chews. Where?

When? (Daytime Nighttime Middle of the night wakes up out of sleep, Always itchy)

Itching worse? (In bed, When warm/wet/cold, At night, In morning/afternoon)

Bleeds Red Swollen Pimples Scabs Blisters Sores Hair loss? Scratched off Fell out

Triggers? Foods?

Seasonal

Winter

Spring

Summer

Fall

Mental Symptoms

Friendly

Playful

Energetic

Affectionate

Outgoing

Fearful

Shy

Skiddish when approached By strangers

By anyone

By kids

Aggressive

Fear-biter when approached by strangers

Ever bitten or tried to bite?

Yes

No

Urinates when scared?

Yes

No

Defecates when scared?

Yes

No

Noises: Afraid

T-storms

Vacuum

Doorbell

Other

Heartworm
Tested for Heartworm?

Yes

No

When?

On preventative?

Yes

No

Product Name:

How often given?

Ever positive?

What age?

Treated conventionally? # of times?

Complications with treatment?

Yes

No

Tested negative after treatment?

Yes

No

Pet's History

Pet Name*

Date of Birth/Age*

Species*

Sex*

Breed*

How long has pet been with you?

Cat indoor or outdoor?

Other pets in home?

Brief explanation in one sentence explaining pet’s problem:

Thirst

Appetite

Number of times fed daily:

Dry Brand:

Canned Brand:

Homemade? Ingredients?

Supplements:

Treats:

Weight

Gums/Teeth

Vomiting

If yes, please describe: How often - daily, weekly, monthly, or yearly? What do they vomit? (Phlegm Bile Food) When? (Seconds to minutes after eating/ Hours later/ Intermittently)

Diarrhea

If yes, how often?

Stool Consistency

Color of Stool

How many times a day?

Can you describe the odor?

Constipation

Straining?

Enemas How often?

Urination Color

Any odor?

Crystals seen?

Straining?

Frequency? Increased, normal, decreased

Vocalizing?

Accidents in house?

If yes, where?

Involuntary Incontinent?

Dribbling urine involuntarily

Bladder stones? What type? ( Many, Few, Big, Small)

Surgery: Bladder Kidney Urethral

Male cats: blocked? How many # times?

Catheterized?

Surgery on urethra?

What age?

Relapses since surgery?

Eyes Discharge?

Color?

When?

Vision?

Which eye?

Nose Discharge?

Color?

When?

Sneezing?

Odor to discharge?

Which side?

Ears Discharge?

When?

Itchy?

Swollen Painful Ulcerated Bleeding Ear problems?

Ear mites in past?

Odor?

When started what age?

Ear problems presently?

For how long?

Cleaning? How often? Product used Other medicines used

Ear flushes done? How often

Past Hematomas?

Which ear?

Nervous System Seizures?

How often?

Age they began?

Known trigger?

History of head injury?

Body during a seizure? (ex: Stands, Lies sternal, Lies on the side, Legs stiff, Front Back Shaking Entire body Legs only Head bobbing Jaw chomping)

Behavior before seizure?

If yes, please describe:
How often - daily, weekly, monthly, or yearly?
What do they vomit? (Phlegm Bile Food)
When? (Seconds to minutes after eating/ Hours later/ Intermittently)

Enemas
How often?

Urination
Color

Bladder stones?
What type? ( Many, Few, Big, Small)

Eyes
Discharge?

Nose
Discharge?

Ears
Discharge?

Nervous System
Seizures?

Skin
Itchy? Started when?

Heartworm
Tested for Heartworm?

Sleep
Where does your companion prefer to sleep?

Medications
Date began/Name/Dose/Frequency

CHRONOLOGICAL ORDER OF SYMPTOMS earliest to present:
For example: diarrhea>ear infection>itchy face>itchy feet>etc.