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Patient Pre-Examination Form
Your Name
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Patient Name
Age
You can help us provide the best possible care for your pet by checking all that apply below:
Bad breath
Decreased appetite
Difficulty chewing
Constipation or difficulty defecating
Diarrhea
Increased urination
Change in urinary habits
Vomiting
Decreased Activity
Stiffness
Weakness
Increased anxiety
Increased irritability
Over grooming
Lumps/bumps or other Skin problems
Increased panting
Increased drinking
Difficulty jumping or climbing
Sleeps more
Scratching at the skin or ears
Coughing
Weight gain
Weight loss
How long has your pet been experiencing the symptoms that you selected above?
Does your pet have any other problems or previous diagnosis? If yes, please explain.
Additional comments/details:
Medications currently taking (including those purchased over the counter)
Any nutritional supplements (including those purchased over the counter or herbs)
Please describe your pets diet:
