Patient Consultation Questionnaire ; Complete this form before your next visit. Please enable JavaScript in your browser to complete this form.Client's Name *FirstLastEmail *Patient's Name *Why is your pet being seen today? *(i.e., vomiting, diarrhea, lethargy, scratching ears, etc.)How long has the problem been going on? *Are you aware of anything that may have caused the symptoms? *(i.e., my pet got into the trash, my pet fell while getting out of the car, etc.)Is your pet's activity *NormalIncreasedDecreasedIs your pet's appetite *NormalIncreasedDecreasedIs your pet's thirst *NormalIncreasedDecreasedIs your pet experiencing any of the following symptoms (check all that apply)CoughingSneezingVomitingDiarrheaIs your pet's coughing *ClearProductiveOtherIf other, please specify *Is your pet's sneezing *ClearMucoidOtherIf other, please specify *Is your pet's vomiting *FoodBileOtherIf other, please specify *Is your pet's diarrhea *SoftLiquidBloodyMucoidIs your pet’s mobility *NormalAbnormal(i.e., any lameness, weakness, dragging toes, etc.)If abnormal, please describe *Does your pet have any new masses? *YesNoIf yes, where? *Does your pet have any skin lesions? *YesNoIf yes, where? *What do you feed your pet (please provide name brand and formula of diet)? *Is your pet on a grain-free or raw diet? *Grain-freeRawNeitherWhat is the volume of food you offer per day? *How often is your pet fed? *Free fed1x/day2x/dayOtherIf other, please specify *What kind of treats do you offer your pet? *How often are treats offered? *What do you do to help maintain the health of your pet’s teeth at home? *(i.e., brushing, dental chews, etc.)How often? *When was your pet’s last dental cleaning? *Were dental x-rays performed? *YesNoUnsureIs your pet on any current medication? *YesNoIf yes, please list all current medications *Is your pet on any supplements? *YesNo(i.e., glucosamine, omega fatty acids, CBD, etc.)If yes, please list all supplements *Is your pet on any heartworm prevention? *YesNoIf yes, please specify *Is your pet on any flea and tick prevention? *YesNoIf yes, please specify *Approximate percentage of time your pet spends indoors *Approximate percentage of time your pet spends outdoors *Has your pet traveled outside the area in the past 12 months? *YesNoIf yes, where? *Do you plan for your pet to travel outside the area in the coming 6 months? *YesNoIf yes, where? *Do you have pet insurance? *YesNoName of insurance company *If you are interested, the Cardiff Animal Hospital will submit claims on your behalf. Please provide us with a blank claim form with your pet’s information pre-printed on it, and we will fax it in after each visit.Does your pet have a microchip? *YesNoUnsureIf yes, we will scan it at the time of each examination to ensure it is working.Are there other pets in the household? *YesNoIf yes, please provide name, species, and age of each *Additional CommentsSignature *Clear SignatureDate *Submit
