IMED Registration Form – RICHMOND

Welcome to Partner Veterinary Internal Medicine! Thank you for giving us the opportunity to care for your beloved pet.

An accurate and current medical history is one of the most important parts of our medical evaluation. Please take a few moments to fill out this questionnaire to provide our internal medicine doctors with insight into your animals’ health and information that may aid them during the comprehensive physical examination.  

Click HERE for a PDF version of this form.

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Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Primary Veterinary Office:

Pet's Name *

Species: *— Select Choice —CatDog

Gender: *— Select Choice —FemaleMale

Spayed/neutered? *— Select Choice —YesNo

Breed: *

What is the primary reason your pet is seeing an internal medicine doctor? *

When did you start noticing the symptoms? *

Has your pet been evaluated for this problem before by another ER, specialist, or primary care veterinarian?YesNo

If yes, please list below:

Which diagnostics were performed?

Which medications were administered and for how long?

How did your pet respond to the treatment?

Has your pet’s general activity level: *

• Increased
• Decreased
• Remained Normal

If increased or decreased, for how long?

Has your pet’s water intake been: *

• Increased
• Decreased
• Remained Normal

If increased or decreased, for how long?

Has your pet’s appetite been: *

• Increased
• Decreased
• Remained Normal

If increased or decreased, for how long?

Does your pet’s diet consist of: *

• Commercial Food
• Prescription Food
• Table Scraps
• Other

Please list food(s):

How much are they eating per serving?

When did your pet last eat? *

Please upload a photo of your pet's food.

Drag & Drop Files, Choose Files to Upload

Have you noticed any changes in your pet’s urination behavior or frequency? *

• Yes
• No

How long?

Frequency / day?

Please describe changes to the urine (color, blood/straining/accidents present)?:

Have you noticed any recent coughing? *

• Yes
• No

How long?

Frequency?

Triggers/Causes?

Have you noticed any recent sneezing? *

• Yes
• No

How long?

Frequency?

Triggers/Causes?

Have you noticed any recent vomiting? *

• Yes
• No

How long?

Frequency?

Triggers/Causes?

Have you noticed any recent diarrhea? *

• Yes
• No

How long?

Frequency?

Please Describe (consistency, blood/mucus present):

Any abnormal discharge from ears, eyes, nose, mouth, rectum, genitals? *

• Yes
• No

Please describe location, any characteristics, duration:

Has your pet traveled out of the state of Virginia within the past year? *

• Yes
• No

If yes, when, and where?

Are your pet vaccines current and within the last 12 months? *

• Yes
• No

Year of last rabies vaccine:

Has your pet been vaccinated with any elective vaccines (such as leptospirosis, Lyme, FeLV and/or FIV) within the past 12 months? *

• Yes
• No
• Unknown

How may medications, including heartworm and flea/tick prevention, is your pet taking? *— Select Choice —None123456

Please describe all medications including heartworm and flea/tick prevention that your pet is taking:

Example:
Name:Gabapentin
Strength: 100 mg
Amount Given: 2 caps
Frequency: Twice daily
Last Given: 8/18 8:00am
Duration: 3 weeks

Medication 1

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Medication 2

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Medication 3

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Medication 4

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Medication 5

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Medication 6

Name *

Strength

Amount Given

Frequency

Last Given

Duration of medication

Please bring any medication that your pet(s) is currently taking to this appointment in its original packaging, with the exception of controlled substances such as gabapentin, hydrocodone, etc).

If medications are to be dispensed, does your pet prefer:

• Pill
• Liquid
• Other

If other, please describe:

Has your pet ever experienced adverse or allergic reactions to any medication?

• Yes
• No

If yes, please describe:

Does your pet have any known food allergies?

• Yes
• No

If yes, which foods?

Has your pet had any significant injuries, illness, surgery, or medical problems in the past that are not covered by the previous questions?

Other pets in the household *

• None
• Dogs
• Cats

1 Has any

How many dogs?

How many cats?

Is your pet and his/her housemates: *

• Indoor Only
• Outdoor Only
• Both

Are any other pets showing the same symptoms as your pet visiting today? *

• Yes
• No

Upload a photo of your pet.

Drag & Drop Files, Choose Files to Upload

Thank you for taking the time to complete this form. Our team may ask you to clarify or provide additional details about any of the above during your visit.

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