Important information to gather when initiating the session (this is usually available to the veterinarian prior to greeting the client):

1. Date of examination (important for medical record entry)
2. Signalment (client and patient identification)
3. Presenting complaint (the reason the client is presenting the animal)

Continue gathering information by developing the presenting complaint (history of the present illness)

• Onset, duration, frequency
• Location, severity
• Progression or improvement of the problem
• Factors that increase or decrease clinical signs
• Have medications been used (product, dosage, duration, response)

Perform a body systems review to identify localizing and non-localizing clinical signs

• Attitude, activity, behavior
• Appetite, weight change
• Water intake and urination
• Presence of vomiting, diarrhea
• Presence of coughing, sneezing
• Additional questions might include (depending on the individual patient):
  • Masses, changes in haircoat
  • Discharge from eyes, nose, vulva, prepuce
  • Change in gait or lameness

Perform a general overview to identify risk factors created by the animal/other animals, the people associated with the animal, and the animal’s environment.

• Environment (where obtained, current environment, lifestyle, travel, other pets)
• Vaccination (what was given and when)
• Diet
• Parasite control (internal parasites, fleas or external parasites, heartworm)
• Past medical history (previous diseases, trauma, surgery)
• Current medications (prescription, over-the-counter, alternative)
• Family history if possible, to assess genetic predispositions
• Current health status