Sick Pet Questionnaire Form

Veterinary Village LLC

Information for your visit for your sick or injured pet

1 Start 2 Complete

Your Name

Pet’s Name

Phone Numbers

Home

Cell

Work

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 NOTE ANY SPECIFIC PROBLEMS NOTICED 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

Veterinary Village LLC

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