Please check one: My pet stays
Inside 100%   Inside mostly  Outside mostly   Outside 100%

Are you a client? Yes   No

Have we seen this pet before? Yes   No

Drop off date:

Number where you can be reached today:

If you have not heard from us by 11:00 a.m., please call us to check on the condition of your pet and arrange a pick-up time.

WELL-VISIT  Please check services requested today.  
If your pet is sick, please click here.

Annual wellness examination/physical exam

Wellness Blood Screening - This test tells us how the internal organs are functioning and includes a complete blood count. This helps us detect problems early, which is important in treatment. We recommend this test every other year until 7 years of age and yearly thereafter. When done with the heartworm test, this lab test is half its normal price. A great value with lots of valuable information!!

Other

Have you seen any worms in the stool? Yes   No
If yes, please describe 

Date of last vaccines 
Type of vaccine given 

Is your pet currently taking any medications? Yes   No
Please list the name, dosage, and frequency 

Is you pet on heartworm prevention? Yes   No
Type of prevention 

Do you give the heartworm prevention year-round? Yes   No

Other Visit

REQUESTED PROCEDURE (if applicable):

HISTORY/CLINICAL SIGNS: Please fill out information to help us identify the problem.

Appetite
Please check:
Normal   Will not eat at all   Eats poorly   Will eat only table food

Vomiting
What is coming up? Food   Mucus   Bile   Clear Liquid
When did you first notice this problem? 
Is your pet still eating? Yes   No
Frequency of vomiting 
How long after eating is your pet vomiting? 

Diarrhea
What consistency is the diarrhea? Soft   Watery
Is you pet straining? Yes   No
What is the frequency of the diarrhea? 
What is the color of the diarrhea? Bloody   Dark   Normal

Listless
How long has this been a problem?
Is there any reluctance to go up or down steps? Yes   No
Will he/she jump on furniture? Yes   No
Do you think that your pet has any pain when moving? Yes   No

Weakness
Do you think your pet has any pain getting up or laying down? Yes   No

Coughing
How long has this problem been going on?
What is the frequency of the coughing?
During exercise? Yes   No
When he/she pulls on the collar? Yes   No
Is it a dry, hacking cough? Yes   No
Is it coughing anything up? Phlegm   Mucus   Clear fluid
Does your pet seem to feel badly or just cough?
Can your pet lay down and be comfortable?
Do you suspect your pet has trouble breathing?

Sneezing
How long has this problem been going on?
Is there any nasal discharge (clear or mucus)
Does your pet chew his/her feet or lick his/her paws
Does your pet rub his/her face on the floor?

Scratching
How long has this problem been going on?
Do you think this problem is worse during certain seasons?
Has your pet had any history of allergies? Yes   No
Have you found any fleas? Yes   No
What type of flea control do you use?
How often do you apply this flea control?
Where on the body is the scratching worst? Feet   Ears   Elbows   Other
Any head shaking? Yes   No
Ear odor or discharge? Yes   No
Face rubbing? Yes   No
Have you been using the medication to help relieve the itching? Yes   No
If yes, please describe type, amount, and frequency
Do you have any other pets? Yes   No
Are they scratching? Yes   No
Other helpful information

Limping
How long has this problem been going on?
When are symptoms worst (when he first gets up/after exercise)?
Which leg(s) is effected?
How often does it occur (occasionally, most of the time)?

Scooting
How long has this problem been going on?
Has your pet had a previous problem with impacted anal glands? Yes   No

Other Problems
Please describe the symptoms and frequency of the problem

Please give us any additional information that you think may help us in diagnosing and treating your pet, such as any previous medical problems or current medications.

If you have not heard from us by 11:00 a.m., we encourage you to call our office to check on your pet.

If surgery or a dental procedure is to be performed, a Procedure Consent form will be required. This can be downloaded on-line and e-mailed to us, if convenient for you, at contact@watereeanimalhospital.com

We will try our best to have this information ready for you to sign when you arrive. We hope this will make better use of your time and be more convenient for you.

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