General Information

  • Patient Information:

    • Age, Sex, Species, Breed

    • Mode of arrival (e.g., walked in, carried, arrived by stretcher, owner-driven, ambulance)

    • Document initial, observable condition (e.g., "ambulatory and alert," "recumbent but responsive," "non-responsive").

    • Include physical indicators such as respiratory effort, vocalizations, or visible injuries.

History of Present Illness

  • Primary Reason for Visit: Clearly document the owner's main concern in their own words. Include specific behaviors or symptoms observed and any relevant context (e.g., "not eating since yesterday" or "difficulty walking after a fall").

  • Onset: Note when symptoms began to understand chronicity, including the specific onset date if known.

  • Location: Describe the specific areas affected (e.g., "limping on left hind leg" or "rash on ventral abdomen").

  • Duration: Document how long the symptoms have been present and any notable patterns (e.g., intermittent vomiting for a week).

  • Progression: Describe whether the symptoms are worsening, improving, or stable to gauge urgency.

  • Triggers/Alleviating Factors: Record any situations that worsen (e.g., activity, eating) or improve symptoms (e.g., rest, certain positions).

Associated Symptoms (Signs and Systems)

System-Specific Observations

  • Constitutional: Anorexia, weight changes, energy level changes, general demeanor, restlessness, or unusual postures.

  • Neurological: Seizures, disorientation, tremors, or hyperactivity.

  • HEENT

  • Respiratory: Coughing, sneezing, or difficulty breathing.

  • Cardiovascular: Signs like collapse, fainting, or lethargy.

  • GI/GU: Vomiting (retching?), diarrhea. Changes in frequency, straining, or abnormalities like blood in urine.

  • Musculoskeletal: Lameness, stiffness, or mobility issues. Note recent trauma.

  • Dermatological: Skin changes, pruritus, or hair loss

Pain and Discomfort

  • Observable Signs of Pain: Vocalization, guarding, reluctance to move.

  • Pain Scale (Colorado State Pain Scale):

    • Score 0: No pain. Normal behavior with no signs of discomfort.

    • Score 1 (Mild): Slight changes in behavior, such as decreased activity or mild guarding.

    • Score 2 (Moderate): Reluctance to move, intermittent vocalization when handled, or visible discomfort.

    • Score 3 (Severe): Continuous guarding, vocalizing, aggression, or avoiding interaction.

    • Score 4 (Extreme): Extreme distress or agitation, such as constant vocalization or frantic movements.

Behavior Changes

  • Temperament Changes: Increased aggression, fearfulness, or avoidance.

  • Routine Changes: Alterations in sleeping patterns or inappropriate elimination.

  • Behavioral Triggers: Stressors like new environments, social interactions, or loud noises.

Past Medical History

  • Medical History:

    • Vaccination history

    • Prior significant medical conditions or diagnoses.

    • Known allergies (medications, food, environmental).

    • Previous surgeries or hospitalizations (type and date).

  • Current Medications:

    • Prescribed medications (name, dose, frequency, and duration).

    • Over-the-counter products and supplements.

    • Responses to prior treatments (effectiveness and side effects).

    • Preventatives

  • Diet and Lifestyle:

    • Current diet (brand, type, quantity, feeding frequency).

    • Are they eating and drinking and last feeding.

    • Dietary changes.

    • Environmental factors:

      • Indoor/outdoor access.

      • Access to social scenarios (dog parks, grooming facilities, daycare).

      • Access to standing water, rivers, lakes, or ponds.

  • Foreign Object/Toxin Ingestion:

    • Access to toys, bones, trash, or other potential foreign bodies.

    • Access to chocolate, xylitol, grapes/raisins, rodenticides, household cleaners, antifreeze, pesticides, or recreational drugs.

Fear and Stress Assessment (Fear Free® FAS)

  • FAS Scale Rating:

    • FAS 0: Relaxed, playful, cooperative. Loose body posture, open mouth, wagging tail (dogs), kneading paws (cats).

    • FAS 1: Mild stress, slight tension, or reduced interest. Lip licking, yawning, slight withdrawal.

    • FAS 2: Moderate stress, reluctance to interact, trembling. Avoiding eye contact, panting, or cowering.

    • FAS 3: Severe stress defensive behaviors. Growling, snapping, hissing, or escape attempts.

    • FAS 4: Extreme stress, unmanageable without intervention. Frantic escape attempts, continuous vocalizations, or overt aggression.

  • Stress Triggers: Document procedural or environmental factors exacerbating stress (e.g., loud noises, handling).

    • Document how the owner perceives the animal's behavior during past veterinary visits.

To add: pain med ok?