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Food
Wet Food Brand: ____________________Amount: ______ Dry Food Brand: _____________________Amount ____
Treats: _____________________________________________________How Often? ___________________
Table Scraps? Y/N What Kind? _____________________________________________________________
Do you feed your pet any dietary supplements? If so, what?
W
Health - Please check all that apply.
o Increase in appetite
o Decrease in appetite
o Not eating
o Increased thirst
o Not drinking
o Frequent urination
o Frequent diarrhea or loose stools
o Increase in quantity of urine
o Strains to urinate or defecate
o “Scoots” rear along floor
o Wakes me to go out at night
o Misses litter box
o Urinates or defecates in places other than the
than the box
o
o Spends time in litter box with no production
o Blood in urine or stool
o Leaves a “puddle” of urine when she gets up
o Vomits daily or weekly
o Coughs frequently
o Sneezes frequently
o Scratches or is itchy frequently
o Licks or scratches at ears, paws or belly
o Noticeable hair loss
o Bumps or Lumps?
o Pain
o
o Labored Breathing
o Limping (associated with exercise) or upon rising
o Lethargy
o Difficulty walking or climbing stairs
o Stares off into space
o Disturbance in sleep/wake cycles
o Paces
o Reduced social interaction with owner
o Loss of normal house training
o Does not recognize friends or family
Behavior –
Please check all that apply.
o High activity level
o Moderate activity level
o Sedentary
o Decreased activity level
o Goes outside frequently
o Indoors Only
o Outdoors Only
o Walks in woods
o Walks in city
o Exposed to other pets
o Boards Frequently
o Travels Frequently
o Exposed to wildlife near home
o Goes near streams, stagnant water
o Obedience/training classes
o Doggie Daycare
o Contact with neighborhood pets
o Dog Park
o Repetitive behaviors
o Any new experiences such as bathing, fireworks, moving, new pet, new baby, visitors?
Have you noticed any behavioral changes? Y/N If yes, please elaborate.
Have you visited another veterinarian since your last visit here? Y/N If yes, please elaborate.
Year Round Heartworm medication: __________________________
Year Round Flea/Tick Preventive: _______________________
Medications (Not necessary if we regularly see your pet, and your pet hasn’t been elsewhere.)
Pet’s First Name: ______________ Last Name: ________________________ Birthdate:_________________
Owner’s Name: ____________________________Address: ________________________________________
Phones: Home: ________________ Work: __________________x____ Cell: ________________________
Emergency Contact: _________________________________Phone: ________________________________
Previous Veterinarian: ___________________________________ Phone: ____________________________
(if applicable)
Is there anything you’d like to discuss with the doctor?
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