Patient:Owner:Date Date Format: MM slash DD slash YYYY What is the reason we are seeing your pet today?Primary Complaints: Check any that apply and describe below: Vomiting Diarrhea Eyes Lethargic Coughing Blood in stool Constipation Ears Lameness/Limping Sneezing Blood in urine Growth/Lump Itching Painful Difficulty Breathing Details on above conditions and indicate on diagram if painful, lumps or growths:Has your pet had an increase/decrease/no change in the following:(Please circle one) DrinkingIncreasedDecreasedNo ChangeAppetiteIncreasedDecreasedNo ChangeUrinationIncreasedDecreasedNo ChangeDefecationIncreasedDecreasedNo ChangeWeightIncreasedDecreasedNo ChangeDid your pet eat today?YesNoIf yes, please list what and the time he/she ate:Has your pet been seen by another veterinarian recently?YesNoIf yes, describePlease read and initial one of the following:Please do exam, $89 (exam + hospital ward) only and call with estimate.Please perform diagnostics/procedures up to $300 until I can be contacted.Please contact me after my pet’s examination.Contact At:(Please contact me after my pet’s examination.)SignatureDate Date Format: MM slash DD slash YYYY
