Towne Square Animal Clinic Drop-Off Form

9401 Towne Square Avenue

Blue Ash, OH  45242

(513) 793-1875

FAX (513) 793-6703     zzzdogdoc@msn.com

Date: _______________________

Client Last Name:____________________    Pet's Name:                               

Please describe your pet's symptoms below:                                                 

                                                                                                                 

Appetite

1. _____ Increased     _____ Decreased     _____ Normal

2. Has not eaten for _____ days.

3. Additional comments: ________________________________________________________

Activity

1. Has your pet's activity decreased, i.e. does he/she seem lethargic? _____________________

2. How long ago did you notice this problem? _________________

3. Additional comments: ________________________________________________________

Diarrhea

1. _____ No     _____ Yes,  How often/how many times per day? ______________

2. How many days? ____________

3. Consistency: _____ Very Watery     _____Semi-solid     _____ Pasty

4. Color: _____ Normal     _____Black & Tarry     _____ Blood     _____ Mucus

5. Additional comments:________________________________________________________

Vomiting

1. _____ No     _____ Yes,  how often? __________

2. For how many days? __________________

3. Consistency:   _____ Yellow foam     _____Mostly food     _____ Hairballs     _____ Blood

4. Additional comments: ________________________________________________________

Coughing

1. Is coughing occurring? _____ No     _____ Yes

2. Does your pet bring anything up? _____ No     _____ Yes,     _____ Mucus     _____ Blood

3. How long ago did you notice this problem? ____________________

4. When does your pet cough? (ex. After exercising, only at night, etc.): __________________

5. Additional comments: ________________________________________________________

Sneezing

1. _____ No     _____ Yes,     _____Wet/discharge     _____ Dry/No discharge

2. Nostrils with discharge:  _____ Left     _____ Right     _____ Both

3. How long ago did you notice this problem? ______________________

4. Additional comments: ________________________________________________________

Increased Drinking

1. Have you noticed your pet 'craving' water, or drinking excessively? _____ No     _____ Yes

2. For how long have you noticed this problem? ________________

3. Additional comments: ________________________________________________________

Urinating

1. Are there any problems? _____ No     _____ Yes, & how long ago did you notice:_________

2. Does your pet seem to strain when urinating? _____ No     _____ Yes

3. Is your pet urinating more than usual? _____ No     _____ Yes

4. Have you seen any blood in your pet's urine? _____ No     _____ Yes

5. Additional comments: ________________________________________________________

Skin Problem

1. _____ Itchy     _____ Sore(s)     _____ Lump(s)

2. For how long have you noticed this problem? _________________________________

3. Location: ______________________________________________________________

4. Additional comments: ________________________________________________________

Ear Problem

1. _____ Right Ear     _____ Left Ear     _____ Both ears

2. For how long have you noticed the problem with the ears? __________________

3. What problems are you noting? _____ Odor     _____ Discharge            

_____ Scratching                 Head Shaking

   

4. Additional comments: ________________________________________________________

Limp/Lameness

1. _____ Right front leg     _____ Left front leg     _____ Right rear leg     _____ Left rear leg

2. When does your pet limp? (ex. Right after waking up, exercise, etc.):___________________

3. Does your pet put weight on the lame leg? _____ No     _____ Yes

4. For how long have you noticed this problem? _____________________________

5. Has your pet had any trauma (ex. fell, ran into something) that could have caused this lameness? _________________________________________________________________

6. Additional comments: ________________________________________________________

Eye Problem

1. _____ Right eye          _____ Left eye          _____ Both eyes

2. Is there a discharge? _____ No     _____ Yes, _____ Clear     _____ Yellow     _____ Green

3. Does the area around the eye(s) seem red/irritated (like pink eye)? _____ No     _____ Yes

4. Does your pet squint excessively or rubs its eye(s) excessively? _____ No     _____ Yes

5. Additional comments: ________________________________________________________

OTHER: Please describe below

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number(s) where you can be reached today: ____________________     ___________________

If you have voice mail at work, how can we get around it to reach you directly? _____________________________________________________________________