Stuart Animal Hospital
Call us: 772-287-2242
stuartanimalhosp@bellsouth .net
History Intake/Sick Pet Form...
Please fill out this form if you have an appointment to bring your pet in and leave them with us for the day. It will enable us to better treat your pet in your absence.
Client First Name Client Last Name Pet's Name Phone Number 1 Phone Number 2
What signs/symptoms is your pet demonstrating that made you concerned about his/her health?
How long has this been a problem?
Is this a recheck of a reoccurring problem?
Date of last appointment for this problem
Is your pet eating?
When was the last time your pet had a full meal?
What brand of food do you feed your pet?
Please mark what type
How long have you fed this diet?
Amount fed daily
Has your pet had anything other than it's regular diet in the past 24 hours?
If yes, Please explain what and when.
Any vomiting?
If yes please describe content and duration...
Any Diarrhea?
If yes please describe content and duration...
Is your pet urinating normally? If not please explain.
Is your pet coughing?
If yes please describe content and duration...
Is your pet sneezing?
Is your pet consuming normal amounts of water? If not please explain...
If yes please describe content and duration...
Is your pet itchy?
Duration?
Date of last Flea/Tick prevention applied?
Please describe any lesions/sores on your pet with location and duration...
Has your pet had any seizures or convulsions?
If so, please list frequency, duration, time of day, how they start and what happens during...
Is your pet scooting?
Duration?
Any lameness/limping?
Please check location...
Duration of lameness...
Is your pet current on vaccinations?
If not, and your pet is found to be healthy, would you like us to vaccinate today?
Does your pet have any allergies to food or medications?
If yes, Please list...
What medications and/or supplements is your pet currently taking?
When did you last administer medication to your pet?
Do you need any refills of medication today?
Please list any refills needed here...
If tests are necessary for diagnosis I approve up to
*** Normal physical exam, 1 Xray, Urinalysis and basic blood work average $350. This does not include any treatment or medications to go home.
If you are not able to authorize up to $350, you will have to schedule an appointment with the doctor. We will not admit your pet without this authorization.
