Cardiology - New Patient Medical History Questionnaire in Las Vegas, NV

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

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:

Hidden

If 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

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.

If yes......Please fill out the following chart: Current medications, herbs, vitamins, or supplements your pet is currently receiving at home:

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.

If yes......Please fill out the following chart:
Current medications, herbs, vitamins, or supplements your pet is currently receiving at home: