Sick Pet Questionnaire Form

Client Information

Your Name

Home Phone

Cell Phone

Work Phone

Patient Information

Pet’s Name

Species

Breed

Age

History

Lifestyle

Family

Travel?

Boarding?

Dog Events?

Diet: Main diet

Amount and frequency of feedings?

Treats/snacks

Any change to diet in the last month?

Allergies to food, medications, or vaccinations?

Current Medications (please include prescriptions, over-the-counter drugs, and any supplements used within the past month)

Are there records from another veterinary clinic that we should be aware of? If so, please provide name of veterinary clinic as well as phone number, and any other names the pet may be listed under.

Symptoms

When was your pet last normal?

What symptoms appeared first, and when did they appear?

Are symptoms improving, worsening, or staying the same since then?

Has your pet been treated for a similar condition previously? Describe medications/response

Please Notes any Specific Problems Noted in the Following Body Systems / Categories

General Activity Level?

Weight Change?

Mobility/Musculoskeletal/Joints?

Appetite?

Thirst/Urination?

Vomiting/Diarrhea?

Coughing/Sneezing/Breathing Changes?

Eyes?

Ears?

Skin?

Behavior?

Reproductive Organs?

Sick Pet Questionnaire Form

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