Patient Review Questionnaire Step 1 of 9 11% What are you current concerns about your pet? 1 2 3 4 5 What outcomes would you like to achieve from your next consult? 1 2 3 4 5 What changes have you implemented to the diet since our first consult? (and/or since our most recent consult? What changes have been tolerated? What changes have not been tolerated? What improvements have you noticed? Any changes or problems with appetite / stool quality / gas since diet changes? What supplements / meds have you started since last consult? What supplements / meds have you stopped? What do you think is working? What do you think is NOT working? What are you happy about? What are you not happy about or struggling with? Current diet Current medications Current supplements Pet Parent First Name: Pet Parent Last Name Secondary Pet Parent Name: Pet relationship: (Dad / Mum / Aunty etc) Please describe your pet using the first 5 words that spring to mindPhone:* Email:* Address:* City Post Code Pet Name: Breed: DOB: DD slash MM slash YYYY Sex: Weight: Colour: Name of local GP Vet Have you requested for the vet history to be emailed to me? Desexed: Yes No Pet insurance: Yes No Name of provider: How did you hear about me: Google search Facebook Instagram Referral Other Referral name: What are your major concerns about your pets health currently:Do you have any concerns about their current treatment plan?What do you think is working? What do you think is NOT working? What are you happy about? What are you not happy about or struggling with? Current diet Current medications Current Supplements Summary of previous health conditions:Has your pet had a blood test before? Yes No Blood Test Date MM slash DD slash YYYY Diet - home prepared / kibble / both? approx. % of muscle meat approx. % of organ meat: approx. % of raw meaty bones: approx. % of vegetables: If Kibble / commercial food, approx. %Any fresh foods added and %: Any raw bones added and %: Any supplements: Any treats: Things your pet loves: Things your pet avoids: Appetite ravenous average intermittent fussy DIGESTIVE SYSTEMAny Gastro upsets? Are they associated with certain foods? Stools Normal loose constipated mucusy, at times bloody colour Flatulence / Burping Yes No Sometimes Vomiting Yes No Sometimes Urination – any recent changes in urination more or less frequently? changes in colour noted? any accidents or straining? Any changes in drinking habits? More less no changes BEHAVIOUR Does your pet ever have the followingAnxiety Yes No Events/situations that induce anxiety: Fear aggression: Yes No Phobias – noise / thunder etc? Yes No Other behavioural issues?Does your pet have a temperature preference: Seeks warmth? Any panting? Seeks cool eg lying on cool tiles any shivering? What is your pet’s temperament: Are they shy outgoing hyperactive lethargic Do they sleep a lot or always on the go? Have there been any changes recently? SKINDoes your pet have any skin sensitivities? Itching scratching smell Where do they lick mostly Paws Belly face thighs all over Times of year the worst? Any food reactions? Any ear problems? How often do you bathe? Product used? MOBILITY Any changes in your pets movement? Any issues getting onto furniture? Any lameness after exercise or reluctance to exercise? Any previous joint injuries, broken bones or surgery eg cruciate repair? MEDICATIONSCurrent medications given: Any side effects noticed? Is your pet easy / difficult to get medication into? What currently works? Current Flea treatment used and frequency: Current intestinal worming treatment used and frequency: Current heartworm prevention used and frequency: VACCINATION HISTORY Puppy / kitten course: Yes No Unsure Last vax date : MM slash DD slash YYYY Type of vaccination Any reactions / changes / health problems following the vaccination noted within the days / weeks following a vaccination? Untitled 95969
