Emergency/Sick Pet Exam
Pet Name
*
Owner Name
*
Phone number you can be reached at
*
Format: (000) 000-0000.
Email
*
example@example.com
What patient are we examining today?
Dog
Cat
Other
What has brought your pet in today?
*
What symptoms have you noticed and how long have they been going on for?
*
What symptom are you most concerned about?
When did your pet last eat? Has their appetite been affected by this problem?
When did your pet last urinate? Defecate?
Have you noticed an increase in drinking and/or urinating?
Yes
No
Has this ever happened to your pet before?
Yes
No
Does your pet have any chronic, on-going health problems, or diseases?
Yes
No
If yes, please specify:
Is your pet currently on any medications or supplements?
Have you given your pet any treatments or medications? Have they helped?
Are any other animals in your home having the same problem?
Do you think has eaten anything that they shouldn’t have (toys/toxins/drugs/etc.)
Is your pet up to date on their vaccines?
Yes
No
If your pet stops breathing, would you like CPR done?
Yes
No
Anything else you would like to mention?
Submit
Should be Empty: