Appointment Date & Time
*
Owner Name
*
Pet's Name
*
Pet's age
*
Male or female?
*
Neutered/Spayed?
*
Species/Breed
*
1. Describe the reason for your visit and any concerns you have regarding your pet
*
2. When did the symptoms start?
*
a. When did the vomiting start?
b. How soon before or after eating does the vomiting occur?
c. Does vomit contain undigested (ie. intact kibble) food?
d. Are there any foreign items in the vomit?
e. Describe the consistency
f. How frequent is the vomiting?
g. Could they have eaten something they shouldn’t have and, if so, what and when?
h. Have you recently changed their diet? If so when did the change occur? What are the names of both the old and new foods?
a. When did the diarrhea start?
b. How frequent is the diarrhea?
c. Is there any blood or mucus in the stool?
d. Describe the consistency.
e. What is the volume of stool?
f. Could they have eaten something they shouldn’t have and, if so, what and when?
g. Have you recently changed their diet? If so when did the change occur? What are the names of both the old and new foods?
a. When did the coughing start?
b. How often do they cough (ie. constant or intermittent)?
c. Describe the cough. Dry/hacking, productive (is there mucous or something else that comes up?), high pitched wheeze etc.
d. Did they lose consciousness before, during or after the cough? If yes, for how long? Did you notice their mucus membrane color (ie. gums)? If yes, were they white, normal pink, red or purple?
e. Have they been around any other coughing pets or been around other animals (outside of your household) in the last 14 days?
a. When did the sneezing start?
b. How often do they sneeze (ie. constant or intermittent)?
c. Is there any nasal discharge? If yes, please describe (ie clear, mucus, greenish yellow, bloody).
d. Does your pet spend any time outside unattended?
e. Have they been around any other sneezing pets or been around other animals (outside of your household) in the last 14 days?
a. Describe the change and when you first noticed it?
b. Is the change noted daily?
c. Has the urine production increased or decreased?
d. When was the last time they produced urine?
e. Is there any straining to urinate?
f. Do they ever posture and not produce any urine?
g. Is the odor stronger then normal?
h. What is the color of the urine (ie. golden, clear, bloody)?
i. Are they urinating in a place that is unusual for them?
j. Did anything else in your pet’s environment change at the time of the noted change in urination (ie. diet, weather, visitor at home, new baby, new pet, new home, vacation, medications, over the counter supplements)?
a. Are they drinking more or less water?
b. When did you first notice the change?
c. Do they share their water bowl/fountain with another pet?
d. Approximately how much water do they drink in one day?
e. Are they drinking from any sources that are unusual for them (ie. bathroom tap, people’s water glasses)?
f. Did anything else in your pet’s environment change at the time of the noted change in water intake (ie. diet, weather, visitor at home, new baby, new pet, new home, vacation, medications, over the counter supplements)?
a. Describe the change(s) noted?
b. When did you first notice the change?
c. Have you noticed any changes in your pet’s weight and, if so, what has the timing been as compared to their change in food intake?
d. Did anything else in your pet’s environment change at the time of the noted change in food intake (ie. diet, weather, visitor at home, new baby, new pet, new home, vacation, medications, over the counter supplements)?
10a. What type of food does your pet eat? Please describe brand and type (canned or dry) and let us know how much and how often you feed them each day
10b. What types of treats (if any) does your pet receive? How much and how often each day?
10c. What types (if any) of human food does your pet eat? How much and how often each day?
10d. Are there any other snacks or supplements that your pet receives on a regular or intermittent basis that have not yet been mentioned?
a. Describe their exercise tolerance before, to what you have noticed now?
b. When did you first notice the change?
c. Does anything make the change better or worse?
12. Do you have any concerns regarding your pet’s general attitude? If Yes, please explain below.
13. Do you believe your pet is in pain? If Yes, please explain below
a. Describe the change?
b. Has there been any urinating/defecating in the house (if they were housebroken before)?
c. Does your pet need to go out more frequently (for urination or defecation)?
d. Has their sleeping pattern changed (ie. awake or pacing at night)?
e. Are they no longer coming when called or getting confused in any way?
f. Do they seem depressed or have they suddenly become more active?
g. Are there ANY signs of aggression or agitation? Please describe in detail.
h. Have they ever taken any type of obedience training?
15. Have there been any changes in their environment or routine that have not already been mentioned above? If Yes, please explain below
16. Are they currently on, or have they recently been on, any prescription medications (from our hospital or anywhere else)? If Yes, please explain below
17. Are you using any other medications or neutraceuticals for your pet (supplements, over-the-counter medications, creams or drops, human medications, vitamins)? If Yes, please explain below
18. Has your pet had any medical appointments, treatment and/or surgery in another hospital? If Yes, when, where and for what condition(s)?
a. How far did they fall?
b. Did anything fall on top of them?
c. How did they seem after the fall?
a. Which leg(s) appears affected?
b. Is the lameness constant or intermittent? If intermittent, what makes it worse or better?
c. Have they ever had issues with this leg before? If yes, when and how was it treated?
a. Describe as best as you can what appeared to happen and for how long
b. How did your pet seem afterwards?
c. Has it happened more than once? If yes, with what frequency?
d. Is there anything that occurred in your pet’s environment that may have triggered this to happen?
a. Did the vehicle hit your pet or physically run over them?
b. Was your pet ever pinned under the car or dragged by the car?
c. Was your pet ever able to stand on their own after being hit? Can they stand now?
d. Are there any body parts in particular that you are worried about?
a. Do you know what type of animal(s) was involved?
b. Did the animal pick up and/or shake your pet?
c. Do you know the owner of the pet who did the biting?
d. Did you get bitten?
e. Did the other animal get bitten by your pet?
f. Do you know the rabies vaccine status of the biting pet?
g. Are there any body parts in particular that you are worried about?
a. Could they have eaten something not intended for cats/dogs or something they don’t normally eat?
b. Is anything missing that could have been eaten?
c. Do they have access to the garbage/have a tendency to get into the garbage?
d. Do they spend time unattended outside?
e. Has any one changed the antifreeze on their car at a location the pet has access to?
f. At any point did your pet seemed dazed?
If you are human, leave this field blank.
