Problem Questions

Name: Plaistow-Kingston Animal Medical Center
Address: 48 Route 125, Kingston, NH, 03848, United States
Telephone: 603-642-9700
Price range: $

Is your pet coming in for a problem? You can fill out this problem form securely online by filling in the form below.

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Problem Questions Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 603-642-9700 for a faster response.

Is your pet coming in for a problem?

You can fill out this problem form securely online by filling in the form below.

All questions with an asterisk after the question require an answer for this form to be submitted properly.

Problem Question Form

Client's Name. *

First

Last

Email *

Species: *

Primary reasons for visit today? (Check all that apply):

ADR
Blood Glucose Curve (Online or Drop-Off)
Blood Glucose Curve (Called In)
Diarrhea
Vomiting
Itching
Other Skin Issues
Coughing
Ear Problem
Eye Problem
Weight Loss
Not Eating
Not Drinking
Eating Ravenously
Excessive Thirst (Polydypsia)
Excessive Urination (Polyuria)
Other Urinary Issues
Hair Loss
Lethargic
Limping
Lump/Mass/Swelling
Seizure-like Episode

How long has diarrhea been going on? *

Any recent exposure to human medications or toxins? *

Yes
No
Unknown

Frequency of diarrhea? *

1-3 times daily
4-6 times daily
More than 6 times a day
Other

If other, please specify. *

Consistency of the diarrhea? *

Very watery
Soft semi-formed stool
Normal stool followed by soft stool
Liquid stool mostly
Bloody diarrhea
Other

If others, please describe. *

Diarrhea color? *

Normal brownish stool color
Very light tan color
Blood tinged color
Very dark color
Almost black in color
Gray pale color stool
Other

If others, please describe. *

Are there any changes in your pet's diet? *

No new changes
Recently changed brands of pet foods
Added new treats
Gave human food scraps or leftovers
Changed from dry or canned food or vice versa
Other

If other, please specify. *

Any recent access to the trash or garbage? *

Yes
No
Not sure
Other

If other, please specify. *

Does your pet chew up toys to other items in the house?* *

Yes
No
Not usually
Has in the past but not lately
Other

If other, please specify. *

Does your pet chew on anything when outside? *

Sticks
Grass
Anything and/or everything
Not usually
Has in the past but not lately
Other

If other, please specify. *

Any medication given for the problem?

Other Information:

Request an Appointment

Is your pet due for a checkup? Have a concern? We pledge to provide compassionate and professional care to pets in Kingston, NH and beyond. If this is a pet emergency, please call (603) 642-9700 or visit Port City Veterinary Referral Hospital - IVG (603-433-0056).

Appointment

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