Patient Info/Exam Sheet "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.Client InformationClient Name* First Last Cell PhoneHome PhoneEmail Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient InformationPatient's Name*#SexMaleFemaleAgePhoneSpeciesBreedAllergiesHistory:What food do you feed your pet?How much does it eat?Problems with urination?YesNoDoes pet urinate more than usual?YesNoIs your pet's vaccines up to date?YesNoWhen are they due?Fecal up to date?YesNoDoes your pet drink more than usual?YesNoIs your pet on heartworm prevention?YesNoWhat Kind?When was the last time given?If pet is not on heartworm prevention, would you like a heartworm test for your pet?YesNoIs your pet on flea control program?What flea control program are you on?When was the last time you applied/gave flea control?If your pet doesn't use flea/tick prevention, would you like to place pet on prevention?YesNoAre there other pets in your household?YesNoAre they treated for fleas?YesNoWhat Kind?Are they on flea control?YesNoDoes pet defecate daily?YesNoHow many times a day does he/she deficate daily?Has your pet experienced vomiting (how often)?Appearance?How many minutes after eating?Has your pet experienced diarrhea (how often)?Appearance?If applicable, has there been blood in the stool?YesNoHas there been blood in vomit?YesNoIs pet coughing?YesNoIf so, how often?Is cough productive?YesNoDoes the pet have eye discharge?YesNoSneezing?YesNoNasal Discharge?YesNoHas your pet had a seizure in the past?YesNoHas pet had a vaccine reaction?YesNoAllergies?Is your pet currently on any medications?YesNoList MedsIs you pet indoor/outdoor or both?Has your cat been Feline Leukemia tested?YesNoIf no, would you like to test?YesNoHow long have you had your pet?Obtained from?Other history information?Interested in teeth brushing or dental care?YesNoInterested in a nutrition plan/consult?YesNoAre there concerns that you would like to inform or ask the Dr about?