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Pre-Examination History Checklist
Please use this form to help us prepare for your pet's visit to our clinic. The more thorough you are in letting us know how your pet is doing, the better!
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1
Patient
First Name
Last Name
Age
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2
Date
-
Date
Year
Month
Day
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3
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Weight Gain
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Weight Loss
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Appetite Increase
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Appetite Decrease
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Vomiting
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Diarrhea
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Constipation
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Difficult Defecation
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4
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Drinking
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Urination
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Coughing
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Sneezing
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Weak after Exercise
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Panting
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Repetitive Pacing
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Repetitive Grooming
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5
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Repetitive Licking
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Overgrooming
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Grooming
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Lumps/Bumps
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Skin Issues
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Itchy/Scratching
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Bad Breath
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Sore Gums
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6
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Difficulty Chewing
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Urinating in House
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Defecating in House
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Muscle Tremors
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Awareness
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Gets Confused/Lost
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Recognition of Family
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Learned Commands
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7
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Affection/Interaction
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Irritability/Aggression
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Fear/Anxiety
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Tolerance of Handling
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased/Selective Hearing
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Excessive Vocalization
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Difficulty Climbing Stairs
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Increased Stiffness
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8
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Weakness/Incoordination
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Waking Family at Night
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Sleeps More
No
Mild
Moderate
Servere
No
No
Mild
Moderate
Servere
Decreased Activity
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9
Other Problems or Concerns?
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10
Medications
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11
Sentinel
Interceptor
Revolution
Other
Other
Sentinel
Interceptor
Revolution
Other
Heartworm Prevention?
Other
Nexgard
Bravecto
Comfortis
Other
Other
Nexgard
Bravecto
Comfortis
Other
Flea/Tick Prevention?
Other
Diet
Previous Medical History
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