Internal Medicine Questionnaire

Pet Name: *

Owner Name: *

Presenting Complaint (Why is your pet coming to see us?)*

SYMPTOMS (Elaborate and include duration as needed)

Appetite
Normal   Decreased   Increased

Thirst
Normal   Decreased   Increased

Stools:
Normal   Decreased   Increased

If abnormal, please describe color and consistency. Any blood, mucus, straining, increased frequency or increased urgency to defecate:

Urinations:
Normal   Abnormal

If abnormal, please describe color, any blood, and straining, leaking, accidents in the house, increased frequency or urgency to urinate:

Vomiting?   Yes   No

If yes, please describe what the vomit looks like and how often your pet is vomiting:

Coughing?   Yes   No

If yes, please describe how often, if coughing is worse at any certain time of the day and if the cough is worsened by exercise or excitement:

Sneezing?   Yes   No

If yes, please describe how often and if any discharge comes out when sneezing:

Nasal Discharge?   Yes   No

If yes, please describe discharge in detail and if coming from one nostril or both:

Do you feel your pet has lost weight? Yes   No

If yes, do you know how much weight has been lost and when you first noticed the weight loss?

Activity level: Normal   Decreased   Increased

Please describe when you first noticed a change in your pet's activity level:

Please describe any abnormal behavior in detail and when it began:

Please describe any other symptoms not listed above:

Has he/she been seen by another veterinarian for any of the above listed problems?
Yes   No

If yes, when/where?

Have any of the following diagnostic tests been performed?

PRIOR MEDICAL HISTORY

Does your pet have any current/past medical problems, allergies, or prior surgeries (other than spay/neuter)?
Yes    No

Please list:

Is your pet up-to-date on his/her rabies vaccination?
Yes    No

CATS

Has your cat been tested for: FeLV (Feline Leukemia Virus)
Yes    No    Unsure

If yes, when?

FIV (Feline Immunodeficiency Virus)
Yes    No    Unsure

If yes, when?

Is your cat:
Indoor Only   Indoor/Outdoor    Outdoor Only

MEDICATIONS

List all medications given to your pet including:

Other medication name/dose/frequency (please list dose in milligrams if known):

Do you feel that any of these medications have helped any of your pet's symptoms?
Yes    No

If yes, please explain which one helped and how

DIET

What is your pet currently eating? (Please list brand, canned or dry, amount fed and how often)

Have you recently changed diets for any reason?
Yes    No

If yes, when?

If you have changed diets for any reason, what is your pet's normal diet?
(Please list brand, canned or dry, amount fed and how often)

MISCELLANEOUS

Do you feel that your pet's symptoms were brought on by anything specific?
(Example: eating something abnormal/different, an injury, new medication, etc...)

Are any other pets in your household ill with similar symptoms? If so, please explain

Did your regular veterinarian recommend any specific tests today?

Is your pet usually friendly at the veterinarian's office?

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