Your Name*:
Your Email*:
Your Phone*:

1. When did your pet start to feel unwell?*

2. Has your pet’s appetite been affected?*

3. How are your pet’s energy levels currently?*

4. What changes are there to your pet’s demeanour?*

5. Has there been any coughing?

6. If so, is it a dry or wet cough? Is your pet bringing anything up when they cough?

7. Has there been any sneezing? If so, is it productive?

8. Is your pet vomiting at all? If so, what is your pet bringing up?

9. Has your pet had any abnormal stool? If so, please reference the below image to tell us what your pet's stool resembles this:
   
   
   

10. Has your pet experienced any change in their water consumption?

11. Has your pet experienced any change to their urination?

12. Has your pet had any recent travel (Local or Internationally)?

13. Is your pet on flea/tick/heartworm prevention?

14. What is your pet’s current diet?

15. Is your pet on any medications?

16. Has your pet experienced any similar symptoms in the past?

*Indicates a required field

Please give us a call if you have any questions or concerns regarding this appointment. Thank you so much for your time. This document provides information for doctors and medical team to start the Patient's examination and prepare a plan to discuss with you during the consultation.
The Staff of Liberty Village Animal Hospital