Internal Medicine New Patient Form (MVA) Please complete the form below prior to your appointment. If you have any questions please email us at info@metro-vet.com. "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Client Name* First Last Pet Name*Client IDHousehold & Medical HistoryHow long have you owned your pet?*Where was your pet obtained?*Your pet is kept primarily:* Outdoors Indoors Indoor ONLY (Cats) Has your pet been boarded or hospitalized within the past month?* Boarded Hospitalized Neither Are there other animals in your household?* Yes No If yes, what animals?What do you feed your pet (brand, formula, home cooked ingredients)?*How much and how often do you feed your pet?*Is your pet fed any treats including table scraps?* Yes No If yes, what types?Is your pet spayed or neutered?* Yes No If yes, how old was your pet when it was spayed/neutered?Other than spaying/neutering, has your pet ever undergone surgery?* Yes No If yes, what surgeries and when?If female and not spayed, when was her last heat?If female, has she had any litters? Yes No If yes, when?AppetiteHas your pet’s appetite changed recently?* Yes No If yes, has your pet’s appetite Increased Decreased How long has your pet’s appetite been abnormal (days/weeks/months)?DiarrheaHas your pet had any diarrhea or abnormal stools recently?* Yes No How long has your pet been having diarrhea and how often does it occur (times per day/week/month)?Is there any blood, mucous, or black discoloration? Yes No Has your pet’s diet changed within a week of the diarrhea starting? Yes No If yes, explainVomitingHas your pet vomited recently?* Yes No Does the vomit contain Foam “Coffee Grounds” Appearance Blood Yellow/Green Bile How long has your pet been vomiting and how often does it occur (times per day/week/month)?Has your pet’s diet changed within a week of the vomiting starting? Yes No If yes, explainCoughingHas your pet been coughing?* Yes No Is your pet coughing more frequently than usual? Yes No How long has your pet been coughing and how often (times per day/week/month)?How long does each coughing bout last?Your pet’s coughing is worse Morning Daytime Evening With Exercise At Rest Nasal Discharge, Sneezing, and BreathingHas your pet had any nasal discharge?* Yes No If yes, discharge color/type Bloody Green Yellow White Clear Does your pet have increased sneezing?* Yes No How long has your pet been sneezing and how often (times per day/week/month)?Does your pet have any difficulty breathing?* Yes No Your pet’s breathing is worse Morning Daytime Evening With Exercise At Rest Does your pet’s tongue or gums ever turn blue?* Yes No Has your pet ever fainted or collapsed?* Yes No Activity LevelHas your pet been more lethargic or not wanting to exercise lately?* Yes No What percentage of normal is your pet’s current activity level (0–100%)?*How long has your pet been lethargic (days/weeks/months)?Additional InformationHas your pet’s weight changed?* Lost weight Gained weight Unchanged If lost or gained, how much?Has your pet ever had a seizure?* Yes No Is your pet’s thirst* Increased Decreased The Same Is your pet’s urination volume* Increased Decreased The Same Has your pet needed to urinate more frequently, been straining, or had abnormal smelling urine?* Yes No Has your pet ever traveled out of the state of Pennsylvania?* Yes No If yes, when and where?Has your pet had unusual or unexpected reactions to medications?* Yes No If yes, please explainHas your pet ever been treated for other major medical problems not listed?* Yes No If yes, please explainMedicationsIs your pet currently taking any medications including monthly preventatives, supplements, or over-the-counter medications?* Yes No List current medicationsMedication NameDosage/Frequency Add RemoveInclude monthly preventatives, supplements, and OTC meds.Agreement & SignatureCancellation Policy Acknowledgment* I have read and agreeI understand I will be invoiced $250.00 if cancelling within 24 hours of the appointment date/time or for no-shows.Initials*Signature*Date* MM slash DD slash YYYY
