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Patient History Questionnaire

Food

Table Scraps?

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Health - Please check all that apply.

Increase in appetite Decrease in appetiteNot eatingIncreased thirstNot drinkingFrequent urinationFrequent diarrhea or loose stoolsIncrease in quantity of urineStrains to urinate or defecate"Scoots" rear along floorWakes me to go out at nightMisses litter boxUrinates or defecates in places other than the than the boxSpends time in litter box with no productionBlood in urine or stoolLeaves a "puddle" of urine when she gets upVomits daily or weeklyCoughs frequentlySneezes frequentlyScratches or is itchy frequentlyLicks or scratches at ears, paws or bellyNoticeable hair lossBumps or Lumps?PainLabored BreathingLimping (associated with exercise) or upon risingLethargyDifficulty walking or climbing stairsStares off into spaceDisturbance in sleep/wake cycles o PacesReduced social interaction with ownerLoss of normal house trainingDoes not recognize friends or family

Behavior – Please check all that apply.

High activity levelModerate activity levelSedentaryDecreased activity levelGoes outside frequentlyIndoors OnlyOutdoors OnlyWalks in woodsWalks in cityExposed to other petsBoards FrequentlyTravels FrequentlyExposed to wildlife near homeGoes near streams, stagnant waterObedience/training classesDoggie DaycareContact with neighborhood petsDog ParkRepetitive behaviorsAny new experiences such as bathing, fireworks, moving, new pet, new baby, visitors?

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Pet Portal

Request an Appointment

Office Hours

Monday 7:30 am - 5:30 pm
Tuesday 7:30 am - 8:00 pm
Wednesday 7:30 am - 5:30 pm
Thursday 7:30 am - 5:30 pm
Friday 7:30 am - 5:00 pm
Saturday Closed
Sunday Closed

CONTACT INFO

16285 Briarwood Trace
Auburn, IL, USA 62615

Phone Number
(217) 615-5500

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