Sick Patient History Questionnaire Client Name * Pet Name * Date of Visit Phone Number * Email * Why is your pet here today? * How long has the problem been present? * Describe the problem in detail * Have you noticed lethargy or change in activity? * Weight loss or gain? Loss Gain OtherOther Vomiting, diarrhea or constipation? Vomiting Diarrhea Constipation Coughing, sneezing, respiratory noise or increased breathing effort? Coughing Sneezing Respiratory noise Increased breathing effort Changes in Appetite Drinking Urination OtherOther What is your pet’s current diet? Has your pet had any recent change in diet or treats? Any unusual table scraps, trash, or access to things in the yard? Any possibility of exposure to poisons? (food, pesticides, rodent killer) Yes No Could your pet have eaten a foreign object (toy, string, trash)? Yes No Is your pet on any medications or supplements? Yes No Is your pet getting around, running, and jumping normally? Yes No Does he/she seem painful? Yes No Does your pet have any chronic medical conditions? Yes No If so, how are they being treated? Has your pet ever had this issue before? * Yes No Captcha Submit If you are human, leave this field blank. Δ