When is your pet's appointment?*

What time is your appointment?*

: HH

MM

What is the reason for your pet’s visit?*

When were your pet’s last vaccines given?*

Does your pet interact with others (ie park, boarding, dog park, etc)?*

Yes
No

Is your pet on flea/tick/heartworm prevention?*

Yes
No

What is the brand and when was their last dose given?*

What diet do you feed your pet? How much and how often do you feed them?*

Is your pet primarily indoor or outdoor or equally both?*

Indoor
Outdoor
Both

Does your pet participate in outdoor activities (ie walks, hikes, swimming, etc)?*

Yes
No

Do you have other pets in the household?*

Yes
No

What kind?*

If your pet’s visit is for sickness or discomfort, please answer the following questions:

Is your pet experiencing coughing/sneezing/vomiting/diarrhea?*

Coughing
Sneezing
Vomiting
Diarrhea

Please describe when it started by date, if it is consistent or intermittent.*

Is the food digested?*

Yes
No

Are there any foreign items in the vomit?*

Yes
No

What is the consistency of the vomit?*

How frequently are they vomiting?*

Could they have eaten something inappropriate?*

Yes
No

Have you recently changed their diet?*

Yes
No

Does the content of the vomitus include food or bile (yellowish frothy saliva)?*

Yes
No

Is there blood?*

Yes
No

Please describe*

How frequently is this occurring?*

Is there any blood or mucus in the stool?*

Yes
No

Describe the consistency of the stool.*

When did the coughing start?*

How often do they cough?*

Describe the cough? Dry/hacking, productive, high pitch wheeze*

Did the patient lose consciousness before, during or after the cough?*

Yes
No

For how long?*

When did the sneezing start?*

Is the sneezing constant or intermittent?*

Constant
Intermittent

Is there any nasal discharge?*

Yes
No

Does your pet spend any time outside unattended?*

Yes
No

Is your urinating as he/she normally does?*

Yes
No

When did it start?*

Is the change daily?*

Yes
No

Has the urine production increased or decreased?*

Increased
Decreased

When was the last time they produced urine?*

Is there any straining?*

Yes
No

Do they ever posture and not produce any urine?*

Yes
No

Any change in appetite or water intake?*

Yes
No

Increase or decrease in appetite? Will your pet still eat treats? When did it start?*

Increase or decrease in water intake? When did it start?*

Have you seen any behavior changes?*

Yes
No

Describe the change.*

Eliminating in the house? Having to go out to eliminate more often?*

Yes
No

No longer sleeping through the night/sleeping pattern changed?*

Yes
No

Seems depressed or has become more active?*

Yes
No

ANY sign of aggression?*

Yes
No

Please describe*

Are there any changes in their environment?*

Yes
No

Are they taking any prescribed medication?*

Yes
No

Please list with strength and instructions of medication(s).*

Are they taking any over-the-counter medications?*

Yes
No

Has the patient had any medical treatment and or surgery in another hospital?*

Yes
No

Please list so we can contact them for medical records.*