Abdominal Ultrasound Patient History Form Client Name * First Name Last Name Email * Phone * Pet's Name * How long have you owned your pet? * How did you obtain your pet? * What are your main concerns for your pet's health? What symptoms are you seeing at home that worry you? * How long have these concerns been present? * Does your pet spend time primarily indoors, outdoors, or both? * Indoors Outdoors Both Do you have a multiple pet household? * Yes No Is your pet having vomiting or diarrhea? If yes, please describe the appearance (blood, mucus, bile, consistency etc) and frequency: * Is your pet having breathing difficulties or coughing? If yes, please describe (panting, noisy breathing, wet or honking cough, etc) * Is your pet having sneezing or nasal discharge? If yes, please describe the frequency and appearance: * What diet does your pet eat (brand and type, main ingredients if known): * Is your pet's appetite normal? If not, please describe whether appetite is increased or decreased: Is your pet drinking a normal amount of water? If not, please describe whether the water intake is increased: Is your pet urinating normal volumes? If not, please describe whether urine volume is increased or decreased: Is your pet having any difficult or painful urinations? Has your pet lost weight recently? * Yes No Does your pet have a normal activity level? If not, please describe: * Is your pet's behavior normal? If not, please describe: * Have you noted any abnormal bleeding? (from gums or nose, in the urine/feces, etc): * Has your pet traveled outside the Pacific Northwest in the past year? * Is your pet up-to-date on routine vaccinations? * Yes No Does your pet receive monthly heartworm and flea preventatives? * Yes No Have you seen a tick attached to your pet in the past six months? * Yes No What medications and/or supplements (including herbs and vitamins) are you giving your pet? If available, please provide the doses: * Does your pet have any previously diagnosed medical problems? * Thank you!
