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Sick Visit Questionnaire
Pets Name
*
Date
*
Owners Name
*
1. Main Concern:
What brings you in today? (Check all that apply)
*
What brings you in today? (Check all that apply)
Coughing
What brings you in today? (Check all that apply)
Sneezing
What brings you in today? (Check all that apply)
Vomiting
What brings you in today? (Check all that apply)
Diarrhea
What brings you in today? (Check all that apply)
Lethargy
What brings you in today? (Check all that apply)
Decreased Appetite
What brings you in today? (Check all that apply)
Increased Drinking
What brings you in today? (Check all that apply)
Urination
What brings you in today? (Check all that apply)
Lameness
What brings you in today? (Check all that apply)
Itching
What brings you in today? (Check all that apply)
Scratching
What brings you in today? (Check all that apply)
Ear Issues
Other
How long has this been going on?
*
Has it been:
*
Has it been:
A
Getting better
Has it been:
B
Getting Worse
Has it been:
C
Staying the same
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