Urinary Questionnaire Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Urinary Questionnaire:Have you noticed any changes in behavior since your last visit?*YesNoExplain:*Is your pet drinking more water than it used to?YesNoUrinating in larger or smaller volumes?YesNowhich oneIs your pet having urinary accidents in the house?YesNoDo they occur in specific locations? -WhereDo the accidents occur while your pet is sleeping?YesNoHave you noticed any straining when your pet urinates?YesNoDescribe your pet’s urine colorIs your pet licking at his/her genitals?YesNoIs there any discharge from your pet’s genitals?YesNoHas a Vet diagnosed your pet with any previous urinary conditions/diseases?YesNoExplain:How was it treated/with what meds?Does your pet receive dry food?YesNoBrandDoes your pet receive canned food?YesNoBrandDoes your pet receive a homemade diet?YesNoType: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?yesnoAny recent changes in the home?yesnoType of litter used at your houseComments: -
