Patient History Questionaire Consult# (Hospital Use Only)(Required) Your Full Name(Required) Your Pets Name(Required) Chief complaint or reason for visit today?(Required) Any vomiting?(Required) No Yes When did it start? Does the vomiting occur during mealtimes or throughout the day? No Yes How soon before/after eating does the vomiting occur? How frequently is the vomiting? If the vomit contains food, is it digested? No Yes Could your pet have eaten something inappropriate, i.e. plants, toys, trash, etc.? Have you seen any foreign material in the vomit? Have you recently changed your pets diet? No Yes What brand and flavor are you feeding and is it wet or dry food? Did you gradually transition to the new food or switch immediately? Gardually Immediately Any diarrhea? No Yes When did it start? How often is your pet having diarrhea? Is there any blood or mucus in the stool? Blood Mucus Select AllDescribe the consistency, i.e. watery, soft, etc.? Could your pet have eaten anything inappropriate? Have you recently changed their diet? No Yes What brand and flavor are you feeding and is it wet or dry food? Did you gradually transition to the new food or switch immediately? Graduallly Immediately Any coughing? No Yes When did it start? How often do they cough? Describe the cough? Does the cough seem to have a trigger, i.e. during walks, playing, excitement? Or does it happen at any time? Does your pet lose consciousness before, during or after the cough? If yes, for how long? No Yes How long do they lose consciousness? Did you notice the color of their gums? Any sneezing? No Yes When did it start? Is it constant or intermittent? Constant Intermittent Is there any eye or nasal discharge? No Yes What is the color and consistency? Has your pet recently been boarded, or gone to the dog parks or groomers? Around any other unknown dogs? No Yes Has the urine production increased or decreased? Increase Decrease No Change When did it start? When was the last time they produced urine? Are they going outside of the litter box or in unusual places? Is there any straining? No Yes Do they ever posture and not produce any urine? No Yes Is the odor stronger than normal? No Yes What is the color of the urine? Is your pet drinking normally? No Yes When did it start? Do they share their water bowl with another pet? Yes No Sometimes How often do you change your pets drinking water? Did anything else change at the time the water intake changed?Any change in your pets eating habits? No Yes When did it start? Describe the change?Has anything changed in the environment at the time the food intake changed?Have you noticed any weight gain or weight loss? What diet are they on and how often/much are you feeding?Do they get snacks or table scraps and if so what kind and how much?Have you seen any behavior changes? No Yes When did it start? Describe the change?No longer sleeping through the night/sleeping pattern changed? No longer coming when called? Is your pet Less Active or More Active? Less Active More Active No Change Has your pets environment changed? No Yes What has changed?Is your pet taking any prescribed medication? No Yes What and how often? Has you pet been previously microchipped? No Yes I don't know Is your pet spayed or neutered? No Yes I Don't Know
