Testing2 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? ———————————————————- 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 SENIOR CAT QUESTIONNAIRESelect issues that apply belowPersonality: Lethargic Hyperactive Depressed Not greeting you Not playing Grooming activity minimized Not enjoying treats Turning aggressive Wool sucking Snappy or grumpy Pain and Discomfort: Declining activity level Trouble keeping balance Trouble getting up Restless Can’t get comfortable Whining or meowing a lot Trouble jumping Stiff legs while walking Stiff legs while running Tail continuously between legs Shaking continuously Heavy continuous panting Mouth pain Hard, dry stool pellets Decrease in bowel movements Problematic Symptoms: Vomiting Diarrhea Blood or mucous in stool Loose stool Continuous discharge in the eyes Rough, Unkept Haircoat Coughing Sneezing “Spraying” randomly Hairballs “Spraying” in specific locations Physical Changes: Cloudy or bloodshot eyes Having vision trouble Bumping into things Disoriented or Confused Not coming when called Not responding to noise Appetite increase Appetite decrease Water consumption increase Water consumption decrease Labored breathing Urinating frequently Lumps and bumps Subtle Changes: Changes in interaction Changes in activity Changes in sleeping habits Changes in food and water consumption Bad Breath Unexplained weight gain Unexplained weight loss Changes in grooming Signs of stress Changes in vocalization Elimination behavior: Inappropriate elimination Has your cat ever urinated or defecated somewhere in the house other than in the litter box? Coments: ———————————————————- 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 SENIOR DOG QUESTIONNAIREPersonality: Tires easily Sleeping more than 13hr/day Depressed Not greeting you Not playing Not Wagging Tail Not enjoying treats Turning aggressive Snappy or grumpy Anxiety Pain and Discomfort: Declining activity level Trouble keeping balance Trouble getting up Restless Can’t get comfortable Whining Yelping Stiff legs while walking Stiffness getting up on a cold morning Tail continuously between legs Shaking continuously Heavy continuous panting Mouth Pain Dull, unkempt hair coat Problematic Symptoms: Vomiting Diarrhea Blood or mucous in the stool Loose stool Continuous discharge in the eyes Excessive loss of hair or excessive shedding Coughing Sneezing Lumps and bumps Loss of Bladder Control PHYSICAL CHANGES: Cloudy or bloodshot eyes Having vision trouble Bumping into things Disoriented or Confused Not coming when called Not responding to noise Appetite increase Appetite decrease Water consumption increase Water consumption decrease Labored breathing Urinating frequently Having accidents in the house Doesn’t recognize you Coments:
