Claiborne Hill Veterinary Hospital
19607 Highway 36, Covington, LA 70433
Office: (985)893-1922    Fax: (985)893-4881
Owner Name:_____________________        Animal Name:________________________
Date:_______________
Patient Problem History
What is the presenting problem? When did you first notice the problem, and how often is this problem occuring?

Have you given medication?  If so, what, how much, and when?

Please circle Yes or No to the following:
Is your pet on Heartworm Preventive? YES/NO (If yes , what brand?) _______________________________________
Is your pet intact? YES/NO (If yes, when was her last cycle?)  ______________________________________________
YES	NO	Eating? (Any table food, if so, what?) ___________________________________________________
YES	NO	Drinking? (MORE or LESS than usual?)___________________________________________________
YES	NO	Urinating? (Frequently/Straining/Bloody?) _______________________________________________
YES	NO	Stool? (Normal/Diarrhea/Constipation?) ________________________________________________
If Diarrhea, is it Soft/Runny/Watery/Bloody and how frequent they are going? _______________________________
YES	NO	Vomiting? (How often?) _____________________________________________________________
YES	NO	Respiratory? (Coughing/Sneezing/Runny Eyes/Runny Nose?) ________________________________
If coughing, is it a Hacking/Wheezing cough? __________________________________________________________
YES	NO	Lameness? (Please specify which leg and when occurs.) ____________________________________
YES	NO	Lethargic? ________________________________________________________________________
What does your pet eat and has there been any change in diet recently? _____________________________________