HomeResourcesFormsCardiology – New Patient Medical History Questionnaire Cardiology – New Patient Medical History Questionnaire New Patient Medical History Questionnaire Thank you for taking the time to completely fill out the following questionnaire. The more we know about your pet, the better we can provide the best medical care.Client Name Pet's Name Date MM slash DD slash YYYY What is your primary concern for today? 1. Was food withheld for today's visit? Yes No a. What time was your pet last fed? b. What food(s) does your pet eat? c. What treats does your pet receive? 2. Has your pet’s activity level changed recently? Yes No If yes... a. Increased b. Decreased 3. Has your pet’s appetite changed recently? Yes No If yes... a. Increased b. Decreased c. Not eating at all 4. Has your pet’s weight changed recently? Yes No If yes... a. Increased b. Decreased 5. Has your pet’s water consumption changed recently? Yes No If yes... a. Increased b. Decreased 6. Has your pet been vomiting recently? Yes No if yes Frequency: If yes... a.Day b. Week 7. Have you noticed any changes in your pet’s defecation recently? Yes No If yes... a. Diarrhea b. Straining to Defecate c. Blood in feces d. Mucus in feces 8. Have you noticed any changes in your pet’s urination habits recently? Yes No If yes... a. Increased b. Decreased c. Straining to urinate d. Blood in urine 9a. Have you noticed any changes in your pet's breathing recently? Yes No If yes, please describe:HiddenIf yes... a. Coughing b. Sneezing c. Difficulty Breathing d. Nasal and/or ocular discharge e. Increased respiratory rate f. Increased respiratory effort 9b. Have you noticed any coughing or gagging? Yes No If yes, please describe:10. Is your pet current on vaccinations? Yes No 11. How long have you owned your pet? 12. Where was your pet obtained? 13. Has your pet had any seizures or fainting episodes? Yes No If yes, please describe:14. Are there any lumps or bumps on your pet? Yes No 15. Do you feel your pet is in pain? Yes No If yes... Where ? If yes...How long? 16. Has there been a recent change in your pet’s behavior? Yes No If yes... Please describe:17. Has your pet been treated for any previous medical conditions or surgery? Yes No If yes... Please describe:18. Has your pet been hospitalized recently? Yes No If yes...When? If yes...Where? If yes.....Reason for hospitalization: 19. Has your pet traveled out of Nevada within the last 5 years? Yes No If yes...When? If yes...Where? 20. Where is your pet kept primarily? Indoors Outdoors 21. Is your pet on any current medications? Yes No If yes......Please fill out the following chart: Current medications, herbs, vitamins, or supplements your pet is currently receiving at home:Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No Please mark or check to add more (value) Add more Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No Please mark or check to add more (value) Add More Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No 22. Has your pet had any reaction to a medication before? Yes No If yes, which medication(s) 23. Has your cat been diagnosed with FeLV? Yes No 24. Has your cat been diagnosed with FIV? Yes No Please write down any other information you would like us to know about your pet:CAPTCHA
