Intake Form

Patient Name (required)

Owner's Name (required)

Sex (required)

Date of birth of patient

Your Email (required)

History

Eyes
Discharges (color/texture/amount)

Vision

Ears

Discharges (color/texture/odor)

Hearing

Nose/Throat/Respiratory

Discharges

Sneezes

Breathing (rough/dry/moist/wheezing/snoring

Coughing (dry/moist/forceful/weak/hacking/time of day/season/affected by weather

Gastrointestinal

Mouth (teeth/gums/salivation)

Appetite (frequency/amount per feeding/food preferences)

Thirst (high/low/normal/quantity/preference for warm or cold/drinking from unusual places)

Vomiting (frequency/time of day/right after eating or drinking/vomits food/vomits bile/dry heaves/vomits without effort)

Gas or Gurgling

Feces (normal/loose/diarrhea/constipation/mucus/blood/straining/frequency/lack of control/odor/color/undigested food)

Diet (brand/flavor/texture/preferences)

Cardiovascular

History of heart/blood pressure abnormalities

Urogenital

Disorders/lab abnormalities

Cystitis (straining/pain/blood/crystals/stones)

Urination (frequent/infrequent/nighttime)

Urinary incontinence (accidents in house/out of box/leaking during rest)

Reproductive

Female: Time/quality of last cycle (if intact)

Vaginal Discharge

Male:

Libido/sperm count/genital problems

Musucolskeletal

Lameness (location/duration/pain/stiffness/better with rest or exercise/severity change over course of day)

Neurologic

Seizures (duration/time of day/frequency)