Medical History Form


Please take a moment an complete the Medical History form in advance of your visit to the Animal Hospital at Bideawee. Once completed and submitted it will allow the staff at the Animal Hospital at Bideawee to understand your pet's current health condition in the context of their entire lifetime health and wellness profile.  This information is important in developing treatment and recovery solutions that work for you and your pet.

Bideawee Location
Select the Bideawee Location for this Form (required)

Owner Information
First Name (required)
Last Name (required)
Email Address (required)
We will only use your email address to communicate important information about your pet’s health or hospital news. If you wish to receive communications about our other programs (adoption, volunteers, pet therapy, memorial park) please check here.
Street Address (1) (required)
Street Address (2)
City (required)
State/Province (required)
Zip/Postal Code (required)
Country (required)
Pet Information
Pet's Name (required)
Preferred Method of Communication (required)

Reason for today's visit? (required)
Medical Questions, 1 of 3
Please provide brief explanation when indicated.

Has your pet had any recent medical problems? (required)


Does your pet have any chronic medical problems? (required)


Does your pet have any allergies? (required)


Is your pet on any medications? Are refills needed? (required)


Has your pet traveled out of state/country? (required)


Was your pet heartworm tested within the last year? (required)


Is pet on heartworm preventative? (required)


Is your pet on flea/tick preventative? (required)


Has your pet been tested for intestinal parasites (worms) in the last year? (required)


Is your dog vaccinated for Lyme Disease? (required)


Does your cat go outdoors? (required)

Medical Questions, 2 of 3
Has your pet showed any of the following signs or symptoms within the last 6 months enough to cause concern?

Bad Breath (required)

Coughing (required)

Sneezing (required)

Diarrhea (required)

Vomiting (required)

Itching (required)

Hair Loss (required)

Tremors or seizures (required)

Lameness or stiffness (required)

Head shaking (required)

Listlessness (required)

Agression (required)

Lumps or bumps (required)

Scooting on rear end (required)

Medical Questions, 3 of 3
Has your pet showed any changes in the following?

Frequency or amount of urination (required)

Water consumption (required)

Weight gain? (required)

Weight loss? (required)

Altered recognition patterns (required)

Change in appetite (required)

Change in sleeping patterns (required)

Visual Acuity (required)

Hearing (required)

Anything else we need to know?
Please select a vet (required)

Review and Confirm
Please review your entries, then click "Submit".