The Animal Hospital of Lynchburg

1705 Memorial Avenue
Lynchburg, VA 24501

(434)845-7021

www.lynchburgvet.com

Sick Pet Questionnaire Form

Client Name: (required)

Pet Name: (required)

What symptoms are you noticing? (required)

Appetite: (required)
Normal
Abnormal
How long since last meal?

Drinking: (required)
Normal
More than normal
Less than normal
Urination: (required)
Normal
More frequent
Less frequent
Blood
Pain
Straining
Vomiting: (required)
Yes
No
If yes, how often? How much? Appearance?

Diarrhea? (required)
Yes
No
If yes, how often? How much? Appearance?

Lethargic? (required)
Yes
No
If yes, how often?

Breathing: (required)
Normal
Abnormal
If abnormal, do you notice panting? Labored breathing? Wheezing?

Cough? (required)
Yes
No
If yes, how frequent? Is the cough dry? Moist? Worse at rest/sleep? Worse with exercise/excitement?

Sneezing? (required)
Yes
No
If yes, How often? Is there nasal discharge?

Eyes: (required)
Normal
Abnormal
If abnormal, which eye? Right? Left? Both?

Ears: (required)
Normal
Abnormal
If abnormal, which ear? Right? Left? Both?

Lameness: (required)
Yes
No
If yes, where? Front left? Front right? Rear left? Rear right? Unsure? Is it improving or worsening?

Trauma:
Do you know of any significant events that have occurred? Unusual activities? Changes in exercise? (required)

Toxins/Trash:
Has your pet gotten into anything abnormal? Is your pet in a fenced yard and leash walked? Does your pet run free? (required)

Is your pet taking any medication? Have you given any over the counter meds such as aspirins? Antihistamines, etc? (required)


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