Medical Appointment Information Form Client Name* First Last Patient Name* Patient Gender* Male Female Neutered Male Spayed Female Patient Age* Phone Number we can reach you at during appointment*Reason for your pet seeing the veterinarian today (select all that apply) Eye problem Ear problem Mouth/dental problem Skin problem Check new or changing lump or bump Coughing/sneezing/difficulty breathing Vomiting and/or diarrhea Blood in vomit or stool Constipation Difficulty Urinating/straining/not urinating Urine or bowel accidents Limping/lameness Stiffness/Soreness/difficulty getting around Change in Appetite (Eating more/less/not eating) Drinking more or drinking less Weight gain or loss Behaviour change (depressed, restless, hiding/lethargic) General 'slowing down' Other Please explain each of the above reasons in detailIs this a new problem?* Yes No When did you first notice this issue? Would you describe it as a sudden or a gradual onset? Since first noticing the problem, do you feel it has been getting worse? Yes No If this is an ongoing or recurring problem, when was your pet last treated? Is this a scheduled follow-up? Has there been an overall improvement since last visit? Yes No Please explainIs your pet currently on any medication(s)?What brand and type (canned or dry) of food is your pet eating? How much? How many meals/day?Please list any additional treats and or supplementsDo you feed your pet table food? Percentage of diet?If known - when did your pet last eat? Was it their regular food? How much?If known - when did your pet last have a bowel movement? Was it normal?If known - When did your pet last urinate? Did they have any difficulty?Please send us any photo you think we may find informative ( #1 )Max. file size: 256 MB.Please send us any photo you think we may find informative ( #2 )Max. file size: 256 MB.Please send us any photo you think we may find informative ( #3 )Max. file size: 256 MB.Any other questions or concerns?CommentsThis field is for validation purposes and should be left unchanged.
