1. What brand of food is your pet currently eating?__________________Is it dry or canned? __________
How much of this food does your pet eat daily? _______________ What type of treats do you give your
pet?___________________________________ Do they eat table food?________ Do you feed in meals
or does your pet have food available at all times?______________________
2. Have you noticed an increase or decrease in yout pet’s appetite? __________ If yes, has this been a
gradual or sudden change and how long have you noticed this?
_______________________________________________________________
3. Have you noticed your pet vomiting? _________If yes, when did you first notice this?
________________________________How frequently is your pet vomiting? _________ Is there any
relationship to eating? _____________Describe the vomitus (color, consistency)
_____________________________________________
4. How many bowel movements does your pet have each day? ______ Is the stool
formed?_______________
5. Have you observed your pet having diarrhea? ________If yes, when did you first notice this?
__________________Is the volume of stool greater or less than normal? __________ Describe the
stool(soft, watery, color, etc.) ________________________ Is there blood or mucus in the
stool?___________________ Does your pet strain while defecating?____________
6. Does your pet ever become constipated and appear to have trouble passing stool? ____________ If yes,
how often? _________________________
7. Do you ever notice your pet scooting his or her bottom along the carpet or cement? _______________
8. Approximately how much water does your pet drink daily? ___________________ Have you observed
an increase or decrease in the amount of water your pet is drinking? ________________ If yes, when did
you first notice this? ________________________
9. Have you noticed a change in the frequency of your pet’s urination? _______________ If yes, when did
you first notice this? _____________________________Approximately how much urine is your pet
producing daily?_________________________
10. Does your pet ever urinate in abnormal places in your house? ___________________ Does your pet
seem consciously aware of this act or do they dribble urine without seeming to be aware?
___________________________ Does your pet strain while urinating? ___________ Have you ever
noticed blood in the urine? ____________
11. Does your pet ever seem to have a discharge coming from their eyes? __________ If yes, describe this
discharge. ________________________________________ Does it come from one eye or both?
_______________ Do your pets eyes ever seem reddened or cloudy to you?
_______________________Does your pet ever paw at his/her eyes or act as though their eyes are painful?
_________________ Do you ever see your pet bumping into things or tripping over objects?
_______________________________
12.Does your pet ever shake his/her head or scratch at their ears? _________________ Do you ever notice a
discharge or odor coming from your pet’s ears? ____________________________ Does your pet seem to
have trouble hearing? _______
13. Do you ever notice a discharge coming from your pet’s nose? _________ If yes, describe it.
___________________________________ Does it come from one nostril or both?
______________________ Does your pet sneeze frequently or ever seem to have trouble breathing?
_________________________________________
14. Have you noticed an odor coming from your pet’s mouth? _____________________ Does your pet ever
have difficulty eating or swallowing? ___________________
15. Does your pet seem to tire more easily during exercise? ____________ Does your pet ever seem weak or
experience collapsing or fainting episodes? _____________________
16. Do you ever notice any coughing or gagging? ___________________ If yes, is this cough productive?
_________ Describe what is produced. ________________________ Describe within what circumstances
you notice the coughing(excitement, after lying down, when sleeping during the night, etc.)
____________________________________
17. Do you ever notice your pet scratching or licking at his/her skin? _________ What areas are they
scratching? __________________________________________ If yes, is this in a certain season of the year
or continuous? _______________________________ Does the itching get worse indoors or outdoors?
_______________________ Have you ever seen any fleas on your pet? _____________
18. Have you noticed any hairloss? ____________ What areas of the body?
________________________________________
19. Have you noticed any odors coming from your pets skin? ______________________ Does your pets
haircoat seem dry or more flakey to you? _________________________
20. Do you ever notice your pet limping? _________If so, what leg? ________________ Does your pet
seem to have trouble climbing or descending stairs? __________________ Does your pet have difficulty
rising or with normal exercise? ______________________
21. Have you noticed any behavioral changes in your pet? _________________________
22. Has your pet ever had a seizure? ___________ How long did it last? _____________ When was the last
time your pet had a seizure? __________________ Describe the seizure.
_______________________________________________________________
23. If your pet is an intact female, when was her last heat cycle? ____________________ Was it normal?
_____________ Has she ever had a litter of puppies? ___________If yes, how many? ____________Have
you noticed any discharge from her vulva. __________ If yes, describe it.
_____________________________________________
24. If your pet is an intact male, have you noticed a change in size or shape of his testicles. __________ Do
you ever notice any penile discharge? _________ If yes, describe it.
______________________________________
25. Have you noticed any new lumps or bumps anywhere on your pet’s body? ________ If yes, where are
they located? _______________________________________ How long have they been present?
_________________________ Have they changed in size or appearance at all?
__________________________________________
26. Is your pet currently on any type of medication? _________ Describe type, how much, and how
frequently it’s given.
_______________________________________________________________________