Pet's Name 

Client Name

**Number at which you can be reached today

Is this a new phone number that we should keep on file? Yes No
Has there been an address change?    Yes    No
If yes, please write in your new address in the box below:

THE MAJOR REASON FOR TODAY'S VISIT

How long has your pet had this problem? 

Progression of problem:  Getting worse         No change 

Are there other health problems that we should be aware of, or concerns that you would like us to address today? If so, please explain.

PLEASE PUT AN "X" IN THE BOX FOR EACH ITEM AS APPROPRIATE:

Appetite:        Decreased             Normal           Excessive   

Water intake:  Decreased              Normal           Excessive  

Vomiting:        Yes                 No          How often   

Bowel Movements:  Decreased             Normal           Increased  

                               Straining        Diarrhea       Blood 

Urination:     Decreased             Normal           Increased  

                               Straining        Diarrhea       Blood 

Attitude:       Normal        Depressed         Less Active  

Current Medications: 

Do the medications help the problem?  

Lastly, is your pet:    A Fear Biter          Aggressive         Hard To Handle  

If your pet is potentially aggressive, PLEASE TELL OUR STAFF!

We always try to make friends with our patients and treat them in a caring and humane way.
However, in the event that your pet won't let us care for him or her, we ask your permission
to sedate.

I give permission to Center Sinai to sedate my pet.  Yes     No

Signature