Microsoft Word - Examination
Name:
Cell Phone:
Pet’s Name:
Email Address:
Referred by:
Is your pet mainly: Indoor / Outdoor / Both
Brand of food fed:
Dry Amt. Fed Daily: ____________________________ Canned Amt. Fed Daily: ___________________________________
Human food given: yes no Treats given: yes no Brand of treats: _____________________________________
Is the pet taking any medications or home herbal remedies? YES ___________________________________________/ NO
Does the pet frequent a: boarding kennel groomer doggie day care/dog park socialize with other pets
What changes have you noticed in your pet’s health, behavior or activities? (check all that apply)
Skin Ears
Itching Itching
Flaking Unpleasant smell
Crusting Redness
Scaling Irritation
Oily Texture Waxy Buildup
Unpleasant smell Discharge
Hair Loss Other
Redness Behavior
Cuts or wounds on the skin Nervous or anxious
Scooting rear end Confused or disoriented
Lumps Seizures
Other Increased barking or meowing
Dental Health Other
Excessive drooling Eating/Bathroom Habits
Bad Breath Changes in urinary frequency or amount
Red Gums Changes in bowel frequency or amount
Broken Teeth Significant weight gain or loss
Sensitivity when chewing on toys Discomfort when going to the bathroom
Rubbing on face Excessive thirst
Change in eating behavior Changes in eating habits
Other Other
Eyes Activity Level
Discharge Lethargic/Inactive
Vision Problems Difficulty walking or climbing stairs
Cloudiness Stiffness when getting up
Lumps Lameness
Other Problems Other
Bothersome cough/sneezing
Runny nose
Vomiting
Other
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