Name *

First

Last

Email *

Phone *

Reason for today's visit: (please select all that apply) *

• Wellness exam / vaccines
• Illness
• Injury

What would you like doctor to know about your pet's health? *

What would you like doctor to know about your pet's illness? How long have they been dealing with the illness? *

What would you like doctor to know about your pet's injury? When did injury occur? *

Pet's Name *

Pet's Breed *

Pet's Age *

How is your pet's appetite? *

• Normal
• Increased
• Decreased

What type of food do you feed? *

How is your pet's water consumption? *

• Normal
• Increased
• Decreased

Has your pet been vomiting? *

• No
• Yes

Please explain.

How is your pet's stool? *

• Normal
• Abnormal

Please explain.

How is your pet's urination? *

• Normal
• Increased
• Decreased
• Painful
• Straining

Has your pet shown any sign of:

• Bad breath
• Behavior changes
• Breathing problems
• Coughing
• Depression
• Difficulty with rising, sitting, jumping, or stairs
• Excessive sleeping
• Gums bleeding
• Limping
• Loss of balance
• Restlessness
• Scooting
• Scratching / chewing
• Shaking head
• Skin masses/lesions
• Sneezing
• Weight changes
• Other

Please explain your pet's bad breath. *

Please explain your pet's behavior changes. *

Please explain your pet's breathing problems. *

Please explain your pet's coughing issues. *

Please explain your pet's depression. *

Please explain your pet's difficulty moving. *

Please explain your pet's excessive sleeping. *

Please explain your pet's bleeding gums. *

Please explain your pet's limping. *

Please explain your pet's loss of balance. *

Please explain your pet's restlessness. *

Please explain your pet's scooting. *

Please explain your pet's scratching and chewing. *

Please explain your pet's head shaking. *

Please explain your pet's skin masses and lesions. *

Please explain your pet's sneezing. *

Please explain your pet's weight change. *

If Other, please explain *

Is your pet on heartworm prevention? *

• Yes
• No

Flea prevention? *

• Yes
• No

Current on vaccinations? *

• Yes
• No

Is your pet on any medications? *

• Yes
• No

Is yes, please list all medications, dosage, and the last date given.

(Feline Only) Does your pet go outside?

• Yes
• No

I understand if my pet is found to have fleas, he/she will be treated at my expense. *

• I have read and understand.

Do we have your permission to sedate/anesthetize your pet if necessary in order to perform an exam, diagnostic test, or agreed upon surgical procedure? *

• Yes
• No

Signature *

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Today's Date *

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