Internal Medicine Initial Form

Medical History: IM Initial

4176 Meridian St, Bellingham, WA 98226 | Phone: (360) 758-2200 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Contact Information
Your name*
What is your preferred method of communication?*

EmailPhone Call
Your email
Phone number where you can be reached today*
(XXX) XXX-XXXX
Your pet's name*
What is your preferred pharmacy?*
Please write name and location.
Information about your pet’s current illness

Please describe your concerns about your pet, what prompted you to seek Internal Medicine consultation and what your goals are of this visit.
What signs have you noticed at home? *
What is the frequency of these signs? *
When did these signs begin? How long has your pet been unwell for? *
Have these signs been getting better, remained the same or gotten worse?*
Have you noticed any pattern in your pet’s signs? *
Has there been an effect on behaviour, appetite, drinking, urination or defecation? *
Information about your pet’s prior medical history

Please list your pet’s previous medical conditions or any previous surgeries.
When did these occur?*
What current treatment is your pet receiving for these conditions?*
Is your pet currently on any medications?

YesNo
Medications

Please list the medications that you are currently giving to your pet. Please include:
- Name of medication(s)
- Frequency that you are administering the medication(s)
- Strength of the medication(s)
- Number of tablets you are giving per dose
You can also upload photos, if easy & convenient:

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General information about your pet
When and where did you acquire your pet?*
Has your pet travelled, either within or outside the state of Washington?*
What is your pet’s usual diet?*
Does your pet have any known medication allergies?*
Has your pet previously received a blood transfusion?*
When was the last time your pet was vaccinated? If you know the vaccine that was administered, please write this down as well.*
Does your pet receive preventative medications (e.g. flea and tick prevention)?*
What is your pet’s home living environment?*
Does your pet live inside and/or outside? What other pets live in the household?
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for internal medicine treatment for your beloved pet:
e.g. I searched Google for 'internal medicine vet near me'; My vet recommends you for internal medicine, I've been here before!
Could this form be better? Share your thoughts with marketing@bbvsh.com
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4176 Meridian Street

(360) 758-2200

Medical History: IM Initial

Contact Information

Information about your pet’s current illness

Information about your pet’s prior medical history

Medications

General information about your pet