Appetite: Very Good Good Erratic Picky Poor Very Poor

Give Us Some Important Information About Your Pet

Pet ______Owner ______Date ______

Habitat:  Indoor only  Mostly indoor  Outdoor only  Mostly outdoor  In and out freely

Appetite:  Very good Good  Erratic  Picky  Poor  Very poor

Change in appetite:  Up  Down Food(s): ______

Diet:  Eats specific meals  Fed free choice % table food ______% treats______% pet food ______

Water Consumption:  Does not drink excessively  Drinks very excessively  Amount up  Amount down

Activity level:  Very active Normal  Very inactive  More active  Less active

YESNO

Do you board your pet?

Does your pet go to pet shows?

Lameness: Which leg(s) ______ Constant  Intermittent Duration: ______

Behavior: Any notable change? ______

Vomiting: If yes, how often? ______Consistancy:______

What is vomited? ______

Is there a relationship to eating?  No  Yes How? ______

Diarrhea:  Occasionally  Frequently Frequency:______

If diarrhea is present: Number of bowel movements per day: ______

Straining to defecate:  Yes  No

Coughing:  Occasionally  Frequently

Sneezing:  Occasionally  Frequently

Nasal discharge:  Pus  Watery  Bloody Duration: ______

Itching:  Seasonal  Year-round  Location(s) on the pet’s body: ______

Increase in Urination:  Accidents  Frequently How often and where? ______

History of fight wounds: How many in the last 2 years: ______

Has tested positive for:  Canine Heartworms  Feline FeLV/FIV Virus If yes, how long ago? ______

Fleas or ticks noted recently

On heartworm preventative?  Irregularly  Regularly Number of months per year: ______

On flea preventative?  Irregularly  Regularly Number of months per year: ______

Medications regularly taken: ______

Summary of your concerns: ______

Has your address or phone number changed since last visit?

New information: ______

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Our fax number: (618) 398-5353