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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
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Weight Gain
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Weight Loss
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Appetite Increase
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Appetite Decrease
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Vomiting
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Diarrhea
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Constipation
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Difficult Defecation
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4
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Drinking
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Urination
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Coughing
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Sneezing
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Weak after Exercise
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Panting
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Repetitive Pacing
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Repetitive Grooming
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5
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Repetitive Licking
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Overgrooming
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Grooming
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Lumps/Bumps
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Skin Issues
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Itchy/Scratching
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Bad Breath
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Sore Gums
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6
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Difficulty Chewing
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Urinating in House
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Defecating in House
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Muscle Tremors
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Awareness
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Gets Confused/Lost
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Recognition of Family
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Learned Commands
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7
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Affection/Interaction
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Irritability/Aggression
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Fear/Anxiety
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased Tolerance of Handling
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Decreased/Selective Hearing
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Excessive Vocalization
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Difficulty Climbing Stairs
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Increased Stiffness
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8
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Weakness/Incoordination
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Waking Family at Night
Please Select
No
Mild
Moderate
Servere
No
Please Select
No
Mild
Moderate
Servere
Sleeps More
Please Select
No
Mild
Moderate
Servere
No
Please Select
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
Please Select
Sentinel
Interceptor
Revolution
Other
Other
Please Select
Sentinel
Interceptor
Revolution
Other
Heartworm Prevention?
Other
Please Select
Nexgard
Bravecto
Comfortis
Other
Other
Please Select
Nexgard
Bravecto
Comfortis
Other
Flea/Tick Prevention?
Other
Diet
Previous Medical History
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