Sick Visit Intake Form Sick Visit Intake Form Owner Information Name * Name First Name First Name Last Name Last Name Email * Phone * Patient Information Pet Name * Species * Dog Cat Breed * Age * Sex * Female Female - Spayed Male Male - Neutered Main Concern for Today’s Visit Select one that best describes the main problem * Vomiting Diarrhea Not eating / decreased appetite Lethargy / low energy Coughing / sneezing Trouble breathing Urinary issues Itching / skin problem Ear problem Eye problem Limping / pain Possible toxin ingestion Injury / trauma OtherOther Some symptoms may require immediate medical attention. Please call our hospital right away at (912) 352-3081 if your pet is experiencing trouble breathing, collapse, seizures, severe bleeding, possible toxin ingestion, or difficulty urinating. When did you first notice this problem? * Has the problem gotten better, worse, or stayed the same? * Is your pet eating normally? * Is your pet drinking normally? * List any medications your pet is taking: Has your pet had this issue before? * If Vomiting How many times has your pet vomited? When did the vomiting start? Is your pet able to keep water down? Is there blood in the vomit? Is your pet also having diarrhea? Yes No If Diarrhea How many times has your pet had diarrhea today? When did the diarrhea start? Is there blood present? Is your pet still eating? Is your pet also vomiting? Yes No If Urinary Issues Is your pet straining to urinate? Is your pet producing urine? Have you noticed blood in the urine? Is your pet having accidents in the house? Is your pet going to the litter box or outside more frequently? If Coughing / Sneezing Is your pet coughing, sneezing, gagging, or wheezing? When did this start? Is your pet acting normally otherwise? Is there nasal discharge? If Ear Problem Is your pet shaking their head? Is there discharge or odor from the ear? Is it one ear or both ears? Have they gone swimming recently? If Eye Problem Is the eye red or swollen? Is your pet squinting? Is there discharge? Is it one eye or both eyes? Was there any recent trauma? If Limping / Pain Which leg is affected? Is your pet able to put weight on the leg? Did a possible injury occur? If Skin / Itching Where is your pet itching? Have you noticed hair loss? Have you seen fleas? Is there anything else you would like the doctor to know before your appointment? Captcha Submit If you are human, leave this field blank.
