Welcome to Westway Animal Clinic. A very important part of any appointment is the history and details that come from you, the pet owner. We ask that you please complete this form, in it’s entirety, prior to your appointment with us. Do not worry if there is a detail you are unsure of, just complete to the best of your ability and we’ll take it from there…

Patient History
Daytime Phone Number
Evening Phone Number
Email



3. Is there any vomiting? If the answer is Yes, please answer questions a - h below *

4. Any diarrhea? If the answer is Yes, please answer questions a - g below *

5. Any coughing? If the answer is Yes, please answer questions a - e below *

6. Any sneezing? If the answer is Yes, please answer questions a - e below *

7. Is your pet urinating as he/she normally does? If the answer is No, please answer questions a - j below *

8. Any change in water consumption? If the answer is Yes, please answer questions a - f below *

9. Any change in food intake? If the answer is Yes, please answer questions a - d below *


11. Has your pet’s exercise tolerance or habits changed? If the answer is Yes, please answer questions a - c below *



14. Any changes in behavior? If the answer is Yes, please answer questions a - h below *





IF YOUR PET HAS BEEN ILL OR IS INJURED, please answer relevant questions below (to the best of your knowledge):


19. If your pet was injured, were you present when the injury occurred? *

20. Did your pet fall? If the answer is Yes, please answer questions a - c below *

21. Is your pet lame/limping/not bearing weight on a leg? If the answer is Yes, please answer questions a - c below *

22. Did your pet lose consciousness or appear to have a seizure? If the answer is Yes, please answer questions a - d below *

23. Was your pet hit by a car? If the answer is Yes, please answer questions a - d below *

24. Was your pet attacked by/in a fight with another animal? If the answer is Yes, please answer questions a - g below *

25. Is your pet just “Not Right”? If the answer is Yes, please answer questions a - f below *
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