Castle Peak Veterinary Service (970)328-5444 / (970)926-1821

                                      DROP OFF: FECAL AND URINALYSIS

Client name:_____________________________________________  
Pet Name:_____________________________________________

Best phone # to reach you at 
Today:__________________Tonight:___________________ date:____


SAMPLE INFORMATION:
Time sample was obtained:______________
Circle one   1st time / Recheck / Wellnes  
Days abnormal:_________________________________________________
Currently on Medications? YES / NO
What Medications:_______________________________________________
Any improvement? YES / NO
What are you currently feeding your pet?_______________________________
Any recent changes in diet?________________________________________
Eating:       LESS / NORMAL / MORE  
Drinking:    LESS / NORMAL / MORE
Energy:      LESS / NORMAL
Comments:_____________________________________________________




      FECAL SAMPLE:                                                      
- Stools appear:      FIRM / SOFT / RUNNY                                                                         
- Vomiting?     YES / NO                                     
- Eat mice, birds or game?     YES / NO
- Mucous or blood in stool?     YES / NO
- Exposed to river / pond water?     YES / NO
- Accident in house?     YES / NO
                                                                                                                   
     URINE SAMPLE:
- Urinating in peculiar places?     YES / NO
- Pain when urinating?     YES / NO
- Increased frequency?     YES / NO
- Straining while urinating?     YES / NO
- Increased volume of urine?     YES / NO
- Blood in urine?     YES / NO