Internal Medicine Questionnaire Patient HistoryPatient is:(Required) New Patient Existing Patient Pet Name:(Required) Client Name:(Required) First Last Phone:(Required)Email:(Required) Date:(Required) MM slash DD slash YYYY Reason for visit today:(Required) How is your pet's:Appetite:(Required) Normal Abnormal If abnormal, please describe: Water intake:(Required) Normal Abnormal If abnormal, please describe: Behavior:(Required) Normal Abnormal If abnormal, please describe: Weight:(Required) Loss Gain No change Please any describe recent weight change: Stool:(Required) Normal Abnormal If abnormal, please describe: Urination:(Required) Normal Abnormal If abnormal, please describe: Vomiting:(Required) Yes No If abnormal, please describe: Respiratory Symptoms:(Required) Normal Coughing Sneezing Wheezing If abnormal, please describe: Eyes:(Required) Normal Abnormal If abnormal, please describe: Ears:(Required) Normal Abnormal If abnormal, please describe: Nasal Discharge:(Required) Yes No If yes, please describe: Have you traveled outside of the state with your pet within the past 12 months?(Required) Yes No If yes, please describe: Please list all of your pet's medical conditions: Add RemovePlease list all of your pet's medications including over-the-counter, vitamins, supplements, herbs:Medication NamePrescribed ByDosage (MGs/Units)When is medication given (AM/PM)Frequency (# of times given per day) Add RemovePlease list any known allergies: Add RemovePlease list past surgical/medical procedures: Add RemoveWhat food is your pet regularly fed? (brand, amount, frequency)(Required) If needed, please provide any additional comments regarding your pet's visit:
