Internal Medicine Questionnaire for Owners Form | Austin Veterinary Emergency Center

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Internal Medicine Questionnaire for Owners Formaves_admin2020-12-14T13:03:17-06:00

Internal Medicine Questionnaire for Owners

Your Name*
Your Email*
Patient Name*
Preferred Pharmacy
Pharmacy Name
Pharmacy Address
Street Address Address Line 2 City State ZIP Code
Pharmacy Phone
Basic History
1. Has your pet traveled outside of Texas in the past?
- Yes
- No
- Unsure
If Yes, when and where?
2. Is your pet on a special food
- Yes
- No
- Unsure
What food? When was it last changed?
3. Is your pet currently getting monthly flea, tick, and heartworm preventive?
- Yes
- No
- Unsure
If so, what product(s):
4. Is your pet current on vaccinations?
- Yes
- No
- Unsure
Which vaccine(s)/date(s)
5. To your knowledge, has your pet had any blood transfusions?
- Yes
- No
- Unsure
6. Where did you acquire your pet?
Age at acquisition:
7. Has your pet had any adverse reactions to sedation or anesthesia?
- Yes
- No
- Unsure
Current concerns:
1. Main goal of today’s appointment:
2. Please check the box that best description of how long your pet’s current signs have been happening.
- My pet is acting normally
- A few days
- A few weeks
- A few months
- A few years
3. On a scale of 1-10, please circle how severe your pets clinical signs were when they started
1 = totally normal for your pet / 10 = most severe signs you’ve ever noted
4. On a scale of 1-10, please circle how severe your pets clinical signs are at the current time
1 = totally normal for your pet / 10 = most severe signs you’ve ever noted
5. Based on any previous veterinary treatments (special diets, medications, therapies) for the current problems, have you noted any improvement in clinical signs at home?
- Yes
- No
- Unsure
Comments
6. Based on any previous veterinary treatments (diets, medications, therapies) for the current problems, have you noted any worsening of clinical signs or development of side effects?
- Yes
- No
- Unsure
Comments
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