Urinary Questionnaire Name* Patient Name Last Name Date* MM slash DD slash YYYY Urinary Questionnaire:Have you noticed any changes in behavior since your last visit?* Yes No Explain:*Is your pet drinking more water than it used to? Yes No Urinating in larger or smaller volumes? Yes No which one Is your pet having urinary accidents in the house? Yes No Do they occur in specific locations? -WhereDo the accidents occur while your pet is sleeping? Yes No Have you noticed any straining when your pet urinates? Yes No Describe your pet’s urine colorIs your pet licking at his/her genitals? Yes No Is there any discharge from your pet’s genitals? Yes No Has a Vet diagnosed your pet with any previous urinary conditions/diseases? Yes No Explain:How was it treated/with what meds?Does your pet receive dry food? Yes No Brand Does your pet receive canned food? Yes No Brand Does your pet receive a homemade diet? Yes No Type:For feline patients: How many cats do you have?How many litter boxes do you have?Have any of your cats ever had a urinary blockage? yes no Any recent changes in the home? yes no Type of litter used at your houseComments: -
