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Sick Visit Questionnaire

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What is your pets name:

*

Owners name:

*

Date:

*

1. Main Concern:

What brings you in today? (Select all that apply)

*

What brings you in today? (Select all that apply)

Coughing

Sneezing

Vomiting

Diarrhea

Lethargy

Decreased Appetite

Increased Drinking

Urination

Lameness

Itching/Scratching

Ear Issues

Other

How long has this been going on?

*

Has it been:

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Getting better

*

Getting worse

Staying the same

2. Appetite, water intake, and bathroom habits

Eating Normally?

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A

Yes

*

B

No

Drinking Normally?

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A

Yes

*

B

No

Vomiting?

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A

Yes

*

B

No

If yes, how often?

*

Diarrhea or soft stool?

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A

Yes

*

B

No

If yes, how often?

*

Any blood?

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A

Yes

*

B

No

Accidents in the house?

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A

Yes

*

B

No

3. Medications and Preventatives

Currently on any medications or supplements?

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A

Yes

*

B

No

If yes, please list:

*

Heartworm prevention?

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A

Yes

*

B

No

*

Flea/Tick prevention?

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A

Yes

*

B

No

*

4. Environment & Exposure

Does your pet:

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Go to groomer

*

Attend Daycare

Board overnight

Any other pets in the home sick?

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A

Yes

*

B

No

Any recent travel, new pets, changes or stressors at home?

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A

Yes

*

B

No

If yes, please explain:

*

5. Medical History

Any chronic conditions or previous diagnoses?

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A

Yes

*

B

No

If yes, please list:

*

Any known allergies to medications or vaccines?

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A

Yes

*

B

No

If yes, please list:

*

Additional Information:

Is there anything else you’d like the doctor to know about your pets health, behavior, or recent changes?

*