Client/Patient Information

Owner Name

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Co-Owner Name (if applicable)

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Phone

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Email

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Pet Name

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Age

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How long has your pet been in your home?

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Appointment Date

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Appointment Time

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Eating/Drinking Habits

What type of food(s) does your pet eat? (Select all that apply)

Dry

Canned

Table Food

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What brand(s) do you feed?

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Please rate your pet's eating or drinking habits:

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How long ago did you notice a change in your pet's appetite?

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How long ago did you notice a change in your pet's water intake?

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Have you noticed your pet dropping food or treats from his/her mouth?

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Have you noticed any drooling or foul odor from your pet's mouth?

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How often does your pet vomit?

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How long ago did you notice this change?

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Additional Comments:

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Urination/Defecation

Is your pet having accidents in the house/outside the litterbox?

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How often?

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Please describe your pet's urination habits:

	Much Less	Less	No Change	More	Much More
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How long ago did you notice this change?

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How often does your pet have diarrhea?

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Additional Comments:

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Mobility & Pain

Have you noticed any falls?

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Please specify:

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Does your pet have trouble climbing stairs/onto furniture?

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Have you noticed any stiffness or limping?

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Please specify:

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Is your pet still interested in going for walks?

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Does he/she still play with toys?

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Does your pet have trouble going coming down the stairs or getting off furniture?

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Does your pet have trouble positioning for urination or bowel movements?

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Additional Comments:

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Behavior

Have you found your pet hiding in new places?

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Is your pet staring into space or staring at walls?

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Have you noticed any new nighttime habits/sleep disturbances?

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Please specify:

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Is your pet walking the walls (leaning on walls or furniture) as he/she walks?

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Additional Comments:

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Sensory

Does your pet respond when you call his/her name?

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Does he/she still react to stimuli (e.g. doorbell, mailman, sound of treat bag crinkling)?

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Have you noticed your pet walking into walls or furniture?

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Additional Comments:

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Current Medications & Treatments

Please list your pet's current medications/supplements. Add more by clicking the "Add Medication/Supplement" at the bottom of the section.

Medication/Supplement {binding ItemNumber}

Medication/Supplement Name

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Drug Strength (e.g. 50mg)

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Dose on Label (e.g. 1 tablet by mouth every 12 hrs)

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How often does your pet receive this medication/supplement?

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Do you need a refill?

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Do you have any questions about this medication/supplement?

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Enter your question(s) here for the veterinarian to address:

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Owner-specific Concerns

Please add any additional questions or concerns you would like to discuss at your pet's appointment:

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