testing Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Preventative Questionnaire:Are you interested in Insurance or Preventative Programs for your pet?*YesNoIs your pet on total parasite prevention?*YesNoIf yes which ones do you use?If no, why not?Facts: Parasites can cause diarrhea, weight loss and skin irritation. Many pet parasites are contagious to humans. According to a study from Auburn University Veterinary School 42% of our pets in the southeastern United States have parasites.Has your pet had a blood test in the last 12 months?YesNoFacts: A yearly blood test will pick up many of the medical conditions that occur in pets before signs of illness occurs.Would you be interested in information about preventative care and recommended food for your pet’s teeth?YesNoFacts: Tooth decay and gum disease is the most common medical problem that Veterinarian’s see. Regular teeth cleanings will remove the odor from the mouth, make your Pet feel better, and will prevent costly extractions as your pet ages. ———————————————————– Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Urinary Questionnaire:Have you noticed any changes in behavior since your last visit?*YesNoExplain:*Is your pet drinking more water than it used to?YesNoUrinating in larger or smaller volumes?YesNowhich oneIs your pet having urinary accidents in the house?YesNoDo they occur in specific locations? -WhereDo the accidents occur while your pet is sleeping?YesNoHave you noticed any straining when your pet urinates?YesNoDescribe your pet’s urine colorIs your pet licking at his/her genitals?YesNoIs there any discharge from your pet’s genitals?YesNoHas a Vet diagnosed your pet with any previous urinary conditions/diseases?YesNoExplain:How was it treated/with what meds?Does your pet receive dry food?YesNoBrandDoes your pet receive canned food?YesNoBrandDoes your pet receive a homemade diet?YesNoType:For feline patients: How many cats do you have?How many litter boxes do you have?Have any of your cats ever had a urinary blockage?yesnoAny recent changes in the home?yesnoType of litter used at your houseComments: - ————————————————————- Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Eye QuestionnaireWhen did the eye condition begin?Has this condition been treated before? If so, what medications were used?Have any eye diseases been diagnosed by a Veterinary Doctor before? If so, what was the diagnosis?Which eye is affected? One eye or both?Are the whites of the eyes frequently bloodshot, i.e. red eyes?YesNoHave you noticed any loss of vision or changes in vision?YesNoDoes your pet have trouble seeing at night?YesNoHave you noticed any cloudiness to the eyes?YesNoIs one pupil a different size from the other?YesNoHave you noticed any rubbing at the eyes?YesNoIs one lid droopy?YesNoWhich eye?Any sneezing, coughing, trouble breathing?YesNoExplain:Any discharge from the eye(s)?YesNoPlease describe:Has your pet ever been tested for glaucoma?YesNoHas your pet ever been tested for dry eyes?YesNoDoes your pet have cataract(s)?YesNoAny swelling of the eye(s)?YesNoExplain:Has your pet ever been seen by an Ophthalmology Specialist?YesNoIf so, explain:Comments:- ———————————————————— Behavioral QuestionaireHow old is your pet?*Does your pet have Separation Anxiety (destructive behavior, intense desire to escape, excessive chewing or salivation, nervous)?YesNoIf yes, how is he or she acting?Does your pet have any behavior issues of concern?YesNoHow long? Comments:Does your pet have any soiling issues, ie urinating, defecating, spraying?YesNoComments:Any chewing or biting concerns?YesNoComments:For dog owners, do you have trouble walking your dog?Do you walk your dog or does your dog walk you (excessive pulling)? Comments:Does your pet have destructive behavior?YesNoComments:Does your pet have a dominant or submissive personality? Submissive urinator?YesNoGrowler?YesNoIs your pet becoming more aggressive or irritable with age?YesNoDoes your pet react negatively to thunderstorms ?YesNoComments:Does your pet like Veterinarians?YesNoComments:Is your pet nervous?YesNoPlease list current medications ———————————————————— Name Patient Name Last Name Date Date Format: MM slash DD slash YYYY Oral and Dentistry Questionnaire:What breed is your pet?Does your pet’s mouth have an odor?YesNoHow often?Do you feed pet food that is approved by VOHC (has seal of approval of Veterinary Oral Health)?YesNoIf so which one?Do you feed canned or dry food?Has your pet had a teeth cleaning and polishing before?YesNoWhen was the last one done?Were X-rays of the whole mouth taken?YesNoHave you noticed any obvious signs of pain in the mouth such as chattering, rubbing the mouth, unusual chewing behavior, excessive slobbering, nibbling behavior, or discomfort when brushing the teeth?YesNoDescribe:Have you noticed any discoloration to any of the teeth?YesNoDescribe:Have you noticed any odd shaped tissues or teeth in the mouth?YesNoDescribe:Has your pet been diagnosed with any medical conditions or diseases in the past?YesNoDescribe:Have teeth been extracted or received treatment in the past?YesNoDescribe:Would you mind if we take photos of your pet to give you and also display in our “Wall of Smiles” photo collection?YesNoInitials:Comments: ———————————————————— Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Poison Questionnaire for CatsSEIZURESAre any of these items present in your house/yard? Please check all that apply. Permethrin (canine flea products) Fluoroquinolone antibiotics Diphenhydramine Amitriptyline (in many antidepressants) Mirtazapine(Remeron) Ibuprofen Tea Tree Oil Alpha Lipoic Acid (found in supplements Minoxidil (Loniten or Rogaine) Acetaminophen Ivermectin/Moxidectin (canine heartworm products Baclofen (Lioresal) Bromethalin (rodenticides) Aspirin ———————————————————— Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Poison Questionnaire for DogsSEIZURESAre any of these PHARMACEUTICAL items in your house? Please check all that apply. Fluorouracil (5-FU) Cream (Carac, Efudex, Fluroplex) Fluoroquinolone antibiotics Amphetamines (Meth) Procaine Penicillin G Isoniazid (Nydrazid) Ibuprofen Phenylpropanolamine (Allegra-D, Zyrtec-D) 5-hydroxytryptophan (5-HTP, antidepressants) Metronidazole Lamotrigine (Lamictal) Diphenhydramine (Benadryl) Ivermectin (Canine HW products) Vilazodone (Viibryd) Phenylbutazone (Bute Tablets)Are any of these PLANT items in your house/yard? Please check all that apply. Mushrooms Sago Palm BrunfelsiaAre any of these FOOD items in your house? Please check all that apply. Xylitol (found in most gum) Chocolate (esp. Dark) Ethanol (Beer, Liquor) CaffeineAre any of these RODENTICIDES/INSECTICIDES in your yard? Please check all that apply. Metaldehyde (Antimilice) Bifenthrin (Ortho Max Lawn & Garden) Strychnine (Morning Glory) 4-Aminopyridine (Avitrol) Zinc Phosphate (Neotrace – 4)Are any of these NON-PHARMECEUTICAL drugs in your house? Please check all that apply. Cocaine Cannabis Amphetamines Synthetic CannabinoidsAre any of these MISCELLANEOUS items in your house/yard? Please check all that apply Ethylene Glycol (Antifreeze) Bees/Wasps (bee sting venom) Play-Doh or Salt Dough ———————————————————— Pain QuestionnaireDo you believe there is pain?YesNoIf yes, how would you rate the pain with 1 being the least and 10 being the highest level of pain?What part of the body do you think is painful?Are there vocalizations that indicate pain?YesNoComments:Is there something about the body position that indicates pain?YesNoComments:Have you noticed any behavioral changes? (i.e., grumpy, aggressive, depression).YesNoComments:How many hours a day does your pet sleep?How many hours a day does your pet “lay around” in a resting position?Is your pet restless at night?YesNoComments:How would you rate your pet’s activity level on a scale of 1 to 10 with 1 being the lowest and 10 being extremely active?Comments:Have you noticed any stiffness in the morning when your pet rises?YesNoHave you noticed any changes in running and jumping?YesNoComments:Have you noticed changes in the hair coat or grooming behavior?YesNoComments:Any back pain, disc disease, arthritis, or any other painful disease diagnosed in the past?YesNoDescribe:Comments: ———————————————————— Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Food QuestionnaireWhat foods do you currently feed your pet? Dry Brand:Wet Brand:Raw food?If known, what are the main ingredients?If known, what sources of protein are in the food?How many calories per cup are in your pets food?How you feed your petHow much food is your pet fed? (cups etc.)What do you use to measure the amount?How often do you feed your pet?How long do you leave the food out?Treats you give your pet: Dry Brand:Soft Brand:If known, what are the main ingredients?How often?How many at a time?How often do you give your pet table scraps How much?List examples:Is your pet on any medications or supplements?YesNoPlease list:Does your pet eat out of the garbage?YesNoDoes your pet eat non-edible objects?YesNoWhat things does your pet try to eat?Does your pet vomit or regurgitate its food?YesNoHow long after eating?