Illness Questionnaire Woody Dudley D.V.M Mitchell Hammock Pet Hospital 255 Alexandria Blvd. Oviedo, FL 32765 (407) 366-7323 • Fax (407) 542-8797 www.drwoody.net Name* Patient Name Last Name Date* MM slash DD slash YYYY Illness QuestionnaireWhat changes in behavior have you noted since the last visit?When did your pet’s problem begin?Is the problem better, worse, or the same?Symptoms:Vomiting? Yes No Color/items in itVomiting undigested food? Yes No Not Sure Abdominal contractions with vomiting? Yes No Not Sure Diarrhea? Yes No If yes, Diarrhea descriptionCircle One Jell-O(shiny) Soft/watery Blood in feces? Yes No Not Sure Black, tarry feces? Yes No Explosive diarrhea? Yes No Frequent defecation? Yes No Not Sure Small quantity? Yes No Large quantity? Yes No Pain or Straining when defecating? Yes No Drinking water frequently/more than normal? Yes No Urinating in large volumes? Yes No Urinating frequently/more often than normal? Yes No Urinating uncontrollably at night? Yes No Urinating in the house? Yes No Blood in the urine? Yes No Not Sure Straining to urinate? Yes No Discharge from genitals? Yes No Licking the genitals? Yes No Coughing at night while sleeping? Yes No Seizures/unconscious? Yes No Seizures with some consciousness? Yes No Coughing when excited? Yes No Strange Behavior? Yes No Coughing/hacking randomly? Yes No Painful? Yes No Location(s):Sneezing? Yes No Sneezing with mucus? Yes No Blind or Night Blindness? Yes No Not Sure Discharge from the eyes? Yes No color:Deafness? Yes No Wound? Yes No History of Allergies? Yes No Allergic toSkin Condition? Yes No Bad Breath? Yes No Discolored Teeth? Yes No Aggressive Behavior/bites? Yes No Trouble Walking? Yes No Trouble Getting up? Yes No Excessive Hunger? Yes No Ear Problems? Yes No Scratching ears? Yes No Painful ears? Yes No Shaking head repeatedly? Yes No Head tilts to one side? Yes No Excessive Hunger with weight loss? Yes No Recurrent lethargy at home? Yes No Rubbing anus on ground/Licking anus frequently? Yes No Excessive Stretching/Trouble getting comfortable? Yes No Tires Easily with Exercise ? Yes No Nervousness? Yes No Labored Breathing? Yes No Does your pet have separation anxiety? Yes No On any medications/supplements? Yes No Please list any medications/supplements your pet is currently taking:Has your pet been diagnosed with any problems in the past? Yes No Please list below:If your pet has more than one problem, what problem do you feel is the highest priority?
