Sick Patient Form

Pet's Name

Vomiting (mark all that apply)

Food

Blood

Phlegm

How often?

Diarrhea (mark all that apply)

Mucus

Blood

Straining

How often?

Eating (mark all that apply)

More

Less

Eating foreign objects

How long?

Drinking

More

Less

How long?

Urination

Painful

Blood noticed

Straining

Not urinating

Excessive urination

How long?

Sneezing/Coughing

Any discharge

Difficulty in breathing

Dry hacking cough

Congested cough

How often is the coughing and/or sneezing?

Which one?

How long?

Color & consistency of discharge if present

Which one?

How long?

Mark all that apply:

Itching

Odor

Discharge

Describe discharge if present

Mark all that apply

Itching/irritation

Hair loss

Fleas

Family members itching

How long has patient been itching? Is it seasonal?

Have you used any new shampoos, dips or topical medications?

Did you have anything new in the house before skin problems (new carpet, etc)?

How often?

How frequent?

How long?

Which leg?

How long?

Any known reaction to medications or vaccines?

Any other pre-existing problems (if new patient)?

Currently on any medications, and if so when was the last dose given?

Is your pet on heartworm prevention? If so, what kind?

If not when was the last preventative given?

Any additional information:

May we start diagnostic tests or X-rays? May we start treating the problem?

Is there a strict limit on the amount to be spent?

To protect the health of all of our patients, if your pet has fleas or ticks we will apply a preventative on him/her at an additional charge.
Unless emergency treatment is required, we intend to discuss with you any other procedures and/or treatments as well as approximate costs before proceeding.

Initials

Pet's Name

Vomiting (mark all that apply)

How often?

Diarrhea (mark all that apply)

How often?

Eating (mark all that apply)

How long?

Drinking

How long?

Urination

How long?

Sneezing/Coughing

How often is the coughing and/or sneezing?

Eyes

Which one?

How long?

Color & consistency of discharge if present

Ears

Which one?

How long?

Mark all that apply:

Describe discharge if present

Skin

Mark all that apply

How long has patient been itching? Is it seasonal?

Have you used any new shampoos, dips or topical medications?

Did you have anything new in the house before skin problems (new carpet, etc)?

Seizures

How often?

How frequent?

How long?

Limping

Which leg?

How long?

Any known reaction to medications or vaccines?

Any other pre-existing problems (if new patient)?

Currently on any medications, and if so when was the last dose given?

Is your pet on heartworm prevention? If so, what kind?

If not when was the last preventative given?

Any additional information:

May we start diagnostic tests or X-rays? May we start treating the problem?

Is there a strict limit on the amount to be spent?

To protect the health of all of our patients, if your pet has fleas or ticks we will apply a preventative on him/her at an additional charge. Unless emergency treatment is required, we intend to discuss with you any other procedures and/or treatments as well as approximate costs before proceeding.

To protect the health of all of our patients, if your pet has fleas or ticks we will apply a preventative on him/her at an additional charge.
Unless emergency treatment is required, we intend to discuss with you any other procedures and/or treatments as well as approximate costs before proceeding.