Animal Doctor Westside Your Other Family Doctor URINARY ISSUES First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. What changes have you noticed? How long have you noticed a change? * Describe the urine: * Does your pet strain to urinate? * Yes No Unsure Does your pet have an increased frequency of urination? * Yes No Unsure When is the last time your pet urinated? * Are urinary accidents active (posturing to urinate? * Yes No Unsure Do you find leaking or puddles after the pet has been lying down? * Yes No Unsure Are there any particular areas around the house that your pet chooses to urinate? * Has your pet had a history of urinary abnormalities in the past? Please explain if yes. * How is your pet's thirst and appetite? * Is your pet experiencing (check all that apply): * Vomiting Diarrhea Lethargy None of the above What kind of food are you feeding? How much per day? Table scraps/ treats? * CATS ONLY: How many litterboxes at home? How many cats? How often are litter boxes cleaned? Any changes in litter? CATS ONLY: How often does your cat go outside? Does he/ she go outside on a leash or on a screened in porch? Is the patient on any medications? Include dosage and frequency. * Are you administering flea/ tick preventative? What type and how often? * Are you administering heartworm preventative? What type and how often? * Do we have permission to perform a urinalysis, radiographs, bloodwork, or any additional diagnostics? * Yes No Unsure Do you have any additional questions or concerns you would like to address with the Doctor today? * Submit If you are human, leave this field blank.