HomeResourcesFormsInternal Medicine – Recheck Patient Medical History Questionnaire Internal Medicine – Recheck Patient Medical History Questionnaire Thank you for taking the time to completely fill out the following questionnaire. This form is filled out at every visit to make sure that we have the most recent and accurate information.Client Name Pet's Name PhoneDate MM slash DD slash YYYY Please list all the primary vet clinics your pet has seen: When was your pet’s last visit with the primary Veterinarian? HiddenBest Contact Number for Today:Wt (kg) Temperature HR RR BP CRT/MM What is your primary concern about your pet today? Was food withheld for today's visit? Yes No Last fed at what time/date? Do you see improvement from the last visit?NoneSlightModerateBack to normalActivity LevelNormalIncreasedDecreasedAppetiteNormalIncreasedDecreasedNot eatingWater ConsumptionNormalIncreasedDecreasedUrination FrequencyNormalIncreasedDecreasedBowel MovementNormalAbnormalDiarrhea Yes No If yes....describe Vomiting Yes No If yes....describe Respiratory Sneezing or Nasal/Ocular Discharge Coughing Difficulty Breathing Describe: Frequency/Describe: Describe: Pain Yes No Describe New Lumps/Bumps: New Lumps/Bumps: Added new treats Unintentional changes (trash/plants/other) (trash/plants/other) Dietary Changes: Please Describe:Medications, Vitamins, or Supplements your pet is currently receiving at home:Name Strength (mg) # of tab/caps Frequency Given Last Given Refill? Y | N Yes No Please check or click here to add more Add More Name Strength (mg) # of tab/caps Frequency Given Last Given Refill? Y | N Yes No Please check or click here to add more Add More Name Strength (mg) # of tab/caps Frequency Given Last Given Refill? Y | N Yes No Previous Medications:Diet History Continued:If applicable, would you like a copy of today’s bloodwork results? Yes No CAPTCHA
