ER Vets4pets - Wildlife Intake

Patient/Owner Information* This field is required.

Patient Name

Date

Owner Name

Are you Military?

What is going on? * This field is required.

* This field is required.

Stools* This field is required.

Color

Consistency

Amount

Frequency

Urination* This field is required.

Color

Frequency

Amount

Straining or vocalization during?

Have you noticed the following symptoms?* This field is required.

Behavior change

Vomiting/regurgitation

Lethargy/decreased activity

Change in stools

Abnormal urination

Change in appetite

Nasal or ocular discharge

Weight change

Coughing

Sneezing

Scratching

Increasing breathing rate/effort

Hair loss/abnormalities

Itching

Skin sores

Excessive shedding

Lameness

Masses or lumps

Vocalization

Head tilt

Loss of balance

Inactivity/hiding

Weakness

None

Other

Please describe the other symptoms your pet is exhibiting.

If your pet has had behavior changes, please describe * This field is required.

If your pet is limping, which leg? * This field is required.

If shedding, masses or skin sores, where? * This field is required.

If weight change, increased or decreased? * This field is required.

Describe any other changes * This field is required.

Have there been any pets in contact with this one that have died within the last month? * This field is required.

YESNO

If yes, explain * This field is required.

Has this pet been sick at any other time during the last 12 months?* This field is required.Please explain:

If so, by whom was it seen?* This field is required.

Has this pet been given any medications or supplements in the past 7 days? * This field is required.

YESNO

If yes, which ones?* This field is required.

Does this pet have any medical conditions?* This field is required.

Does this pet take any medications regularly? If so, list medications and dosing * This field is required.

* This field is required.

Housing information* This field is required.

House temperature* This field is required.

Day time

Night time

* This field is required.

Cleaning schedule/products

Is this pet housed with another animal?

* This field is required.

Species

Age

Number and sex of cage mate(s)

* This field is required.

Are there any other pets in the house?

If so, what kind?

If so, are they exposed to the pet(s)?

* This field is required.

Is your pet being seen for Vomiting and/or Diarrhea?* This field is required.

YESNO

What percentage of food does your pet eat?
Pellets   * %
Seed    * %
Table food    * %
Other     * %

Types and percentage of table food your pet eats:
Fruits   *    %
Vegetables    * %
Other    * %

* This field is required.

Please verify that you are human* This field is required.