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* Date Format: 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?YesNoColor/items in itVomiting undigested food?YesNoNot SureAbdominal contractions with vomiting?YesNoNot SureDiarrhea?YesNoIf yes, Diarrhea descriptionCircle OneJell-O(shiny)Soft/wateryBlood in feces?YesNoNot SureBlack, tarry feces?YesNoExplosive diarrhea?YesNoFrequent defecation?YesNoNot SureSmall quantity?YesNoLarge quantity?YesNoPain or Straining when defecating?YesNoDrinking water frequently/more than normal?YesNoUrinating in large volumes?YesNoUrinating frequently/more often than normal?YesNoUrinating uncontrollably at night?YesNoUrinating in the house?YesNoBlood in the urine?YesNoNot SureStraining to urinate?YesNoDischarge from genitals?YesNoLicking the genitals?YesNoCoughing at night while sleeping?YesNoSeizures/unconscious?YesNoSeizures with some consciousness?YesNoCoughing when excited?YesNoStrange Behavior?YesNoCoughing/hacking randomly?YesNoPainful?YesNoLocation(s):Sneezing?YesNoSneezing with mucus?YesNoBlind or Night Blindness?YesNoNot SureDischarge from the eyes?YesNocolor:Deafness?YesNoWound?YesNoHistory of Allergies?YesNoAllergic toSkin Condition?YesNoBad Breath?YesNoDiscolored Teeth?YesNoAggressive Behavior/bites?YesNoTrouble Walking?YesNoTrouble Getting up?YesNoExcessive Hunger?YesNoEar Problems?YesNoScratching ears?YesNoPainful ears?YesNoShaking head repeatedly?YesNoHead tilts to one side?YesNoExcessive Hunger with weight loss?YesNoRecurrent lethargy at home?YesNoRubbing anus on ground/Licking anus frequently?YesNoExcessive Stretching/Trouble getting comfortable?YesNoTires Easily with Exercise ?YesNoNervousness?YesNoLabored Breathing?YesNoDoes your pet have separation anxiety?YesNoOn any medications/supplements?YesNoPlease list any medications/supplements your pet is currently taking:Has your pet been diagnosed with any problems in the past?YesNoPlease list below:If your pet has more than one problem, what problem do you feel is the highest priority?
