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* 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? ———————————————————- 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 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 grumpyPain 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 movementsProblematic 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 locationsPhysical 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 bumpsSubtle 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 vocalizationElimination 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* Date Format: 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 AnxietyPain 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 coatProblematic 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 ControlPHYSICAL 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 youComents:
