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Owner's Name
Pet's Name
Email Address
Phone
Date
Habitat
Indoor
only
Mostly
Indoors
Outdoor
Only
Mostly
Outdoors
In
and
Out
Freely
Near
Pond,
Lake,
creek,
Barn
Appetite
Very
good
Good
Erratic
Picky
Poor
Very
poor
Change in appetite
None
Up
Down
Food(s)
Diet
Eats
specific
meals
Fed
free
choice
Percentage Table Food
Percentage Treats
Percentage Dog/Cat Food
Thirst and Urination
Normal thirst
Drinks excessively
Urinates more
Urinates less
Accidents in house
Activity Level
Very
active
Normal
Very
inactive
More
active
Less
active
Any allergies or allergic reactions (e.g., to Vaccines)?
Yes
No
Please list any foods, medicines, or vaccines your pet is allergic to.
Do you board your pet?
Yes
No
Lameness?
Yes
No
Which leg(s) are lame?
Is the lameness constant or intermittent?
How long has the lameness lasted?
Noticeable changes in behavior?
Yes
No
Please explain the behavioral changes.
Seizures?
Yes
No
When did the seizures start?
How often do the seizures occur?
How long do the seizures last?
Vomiting?
Yes
No
If yes, how often does your pet vomit?
What is vomited?
Is there a relationship to eating?
Yes
No
How long after eating?
Diarrhea?
Yes
No
Is the diarrhea occasional or frequent?
Occasional
Frequent
How frequent is the diarrhea?
Number of bowel movements per day?
Is your pet straining to defecate?
Coughing?
Yes
No
If yes, how often does your pet cough?
Sneezing?
Yes
No
If yes, how often does your pet sneeze?
Nasal discharge?
Yes
No
Please describe the nasal discharge.
Skin growths or tumors?
Yes
No
Where are the skin growths / tumors located?
How long have they been present?
Itching?
Yes
No
Is the itching seasonal or year-round?
Where is the itching located on the body?
History of fight wounds?
Yes
No
How many fight wounds in the last 2 years?
Has your cat tested positive for Feline Leukemia Virus?
Yes
No
If yes, how long ago?
Has your cat tested positive for Feline AIDS Virus?
Yes
No
If yes, how long ago?
Fleas or ticks noted recently
Yes
No
Is your pet on heartworm preventative?
Yes
No
How frequently do you use heartworm preventative?
How many months per year do you use the heartworm preventative?
Is your pet on flea preventative?
Yes
No
What flea preventative product do you use?
How frequently do you use flea preventative?
How many months per year do you use the flea preventative?
Medications regularly taken:
Summary of your concerns:
Has your address or phone number(s) changed since last year? If so please list your new contact information.
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