Dr. Naidoo Ultrasound Patient History Form Please enable JavaScript in your browser to complete this form.Owner's Name *FirstLastPhone *Email *Pet's Name *Age/Date of Birth *Breed *Sex *MaleMale (neutered)FemaleFemale (spayed)Primary Care Veterinarian *Dr. Jennifer BeedleDr. Gary HuntDr. Katie MarcusDr. Jill PalmerDr. Sheryl RejbaDr. Danielle SklovenDr. Giselle TolsonDr. Lisa YungHow 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: *IndoorsOutdoorsBothDo you have a multiple pet household? *Is your pet having vomiting or diarrhea? *YesNoIf yes, please describe the appearance (blood, mucus, bile, consistency, etc.) and frequency. *Is your pet having breathing difficulties or coughing? *YesNoIf yes, please describe (panting, noisy breathing, wet or honking cough, etc.). *Is your pet having sneezing or nasal discharge? *YesNoIf 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? *YesNoIf not, please describe whether appetite is increased or decreased. *Is your pet drinking a normal amount of water? *YesNoIf not, please describe whether the water intake is increased or decreased. *Is your pet urinating normal volumes? *YesNoIf not, please describe whether urine volume is increased or decreased. *Is your pet urinating more frequently? *YesNoIs your pet having any difficult or painful urinations? *YesNoHas your pet lost weight recently? *YesNoDoes your pet have a normal activity level? *YesNoIf not, please describe. *Is your pet's behavior normal? *YesNoIf not, please describe. *Have you noted any abnormal bleeding (from the gums or nose, in the urine/feces, etc)? *YesNoHas your pet traveled outside the Pacific Northwest in the past year? *YesNoIs your pet up-to-date on routine vaccinations? *YesNoDoes you pet receive monthly heartworm and flea preventatives? *YesNoHave you seen a tick attached to your pet in the past six months? *YesNoWhat 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?Submit