Medical History Form for Veterinary Practices: What Questions to Ask and How the Answers Are Recorded in the Medical Record

The medical history is the pet owner’s account of the animal and the visit. It guides the questions the veterinarian asks, what is examined, and how the medical record begins. A medical history form helps the practice ensure that the same information is recorded at every visit, regardless of who sees the animal.

Two ways to use the form

Practitioners use the medical history form in two ways. One form can be filled out by the pet owner before the visit—at home or in the waiting room—so that the veterinarian has an idea of the reason for the visit even before the examination begins. Another form can be used by the veterinarian as a guide during the consultation, ensuring that the medical history is reviewed in the same order every time.

Both methods work, and many practitioners combine them. A completed form is no substitute for a conversation, since the pet owner often recalls more details when the veterinarian asks follow-up questions.

This is what the form should ask

The form is intended to capture what the pet owner can report, not what the veterinarian assesses. A form for most visits includes the following:

  • Information about the animal, such as species, breed, age, and sex.
  • The reason for the visit, in the pet owner's own words.
  • When the symptoms began and how they have progressed since then.
  • Previous illnesses, surgeries, and visits to other veterinarians.
  • Medications and dietary supplements the animal is currently taking.
  • How the animal eats, drinks, pees, and poops, and how it behaves at home.

Keep the form short enough that the pet owner will be willing to fill it out. Specific questions regarding, for example, dermatology or orthopedics are better suited for separate forms designed for those types of visits.

The source of each piece of information

The medical record must indicate the source of each piece of information. Information provided by the pet owner is kept separate from what the clinic staff has personally observed, examined, or measured. In the SOAP format, the pet owner’s information belongs in the subjective section, and phrases such as “according to the pet owner” indicate to the reader that the information is reported but not verified. How the format works is described in the guide on SOAP records for veterinarians.

A medical history form makes that distinction clear from the start, since all the information on the form comes from the pet owner. Mixing up different types of information is one of the common errors in medical records, and more such errors are discussed in the article on the most common mistakes in medical record-keeping.

Paper or digital

A paper form is easy to implement but must be transcribed into the medical record afterward. A digital form can be sent to the pet owner before the visit or filled out on a tablet in the waiting room. Before making a decision, the practice needs to answer a few questions:

  • Should the form be sent with the booking confirmation or filled out on site?
  • How do the answers get into the medical record without anyone having to enter them again?
  • Which staff member reviews the responses before the animal is brought in?
  • What happens if the pet owner hasn't filled out the form?
  • How are visits handled when someone other than the owner accompanies the animal?

If the practice’s medical records system can accept form responses directly, it saves a step. Ask your vendor about this, and read more about what the medical records system should be able to do in the guide to medical records systems for veterinarians.

Personal Information on the Form

The form collects information about the pet owner, not just about the pet. Therefore, ask only for the information the practice needs for the visit, and avoid questions about the pet owner that are not related to the pet’s care. For a digital form, the practice also needs to know where the responses are stored and how long they are retained; these questions should be directed to the form provider.

Medical History When AI Writes the Medical Record

When the practice uses AI for medical record-keeping, the patient history is discussed during the consultation. Vetz listens to the conversation with the pet owner and writes a structured draft of the medical record based on the practice’s own templates. Vetz can also highlight sections missing from the draft—such as the patient history—so that the veterinarian can ask follow-up questions before the medical record is finalized.

The veterinarian always reviews and approves the draft. The AI cannot know information that was never spoken aloud, so findings noted silently during the examination need to be added—for example, by dictating them afterward. The difference between AI that listens and AI dictation is described in the article on AI dictation, and the entire workflow is outlined in the guide on AI record-keeping for veterinarians.

A Framework to Build Upon

The practice can create its own form based on the points above and adapt the order to fit its medical record template. A simple order is to start with information about the animal and the reason for the visit, continue with the history of the symptoms and previous illnesses, and conclude with medications and how the animal is doing at home. Having the same order in the form and in the medical record template makes it easier to transfer the responses and compare visits over time.

Learn more about Vetz

Would you like to see how Vetz extracts the patient history from the conversation and places it in the correct section of the medical record? Schedule a demo, and we’ll show you how it works using your own medical record templates.