Owners Name* First Last Pet’s Name*Daytime Phone*Alternative PhonePet is here forExam & VaccinationsSickness-InjurySickness-InjuryPlease describe sickness/injury*How long has your pet experienced this condition?*Has the condition occurred in the past?*YesNoHow was it treated?*Has your pet been receiving any medication?*YesNoIf yes, what and how often?*Do we have permission to perform blood work if necessary?*YesNoInitial here*Do we have permission to take x-rays and sedate you pet if needed?*YesNoInitial here*General InformationYour pet’s appetite is normal/excessive/poor/absent?*What is your pet fed?*Water consumption is: the same/increased/decreased?*Energy level is: the same/increased/decreased?*Has your pet been coughing?*YesNoSneezing?*YesNoHas your pet been exposed to any other animals?*YesNoWhat and when?*Gastrointestinal SystemIs your pet vomiting?*YesNoLast vomited?*Your pet’s bowel movements are: normal/hard/soft/diarrhea/bloody/unsure?*Last bowel movement*Frequency*Voluntary/Involuntary*Could your pet have eaten something other than its food?*YesNoWhat?*Could your pet have been exposed to any toxins i.e. fertilizers, chemicals?*YesNoWhat?*Urinary SystemIs your pet straining to urinate?*YesNoIs your pet urinating frequently?*YesNoDoes your pet have bloody urine?*YesNoDoes your pet have bloody urine?*YesNoOdor?*YesNoBlood tinged?*YesNoLast urinated?*How much?*SkinIs your pet itchy?*YesNoIs the skin red?*YesNoIs the skin oozing?*YesNoFirst noticed problem?*Is your pet on flea control?*YesNoIs there a lump?*YesNoIs the lump getting larger/smaller/staying the same?*Where on your pet is the skin problem or lump?*Muscular and Skeletal SystemIs your pet's leg(s) lame*YesNoIn which leg(s) is your pet lame?*First noticed lameness?*Has the lameness gotten worse/better/stayed the same?*Has your pet been licking or biting at specific areas?*YesNoPlease explain*Please give a brief history of the event(s) that may have caused this, if known*Anything else?*Date* Date Format: MM slash DD slash YYYY Signature of Owner*
