testing Name* Patient Name Last Name Date* MM slash DD slash YYYY Preventative Questionnaire:Are you interested in Insurance or Preventative Programs for your pet?* Yes No Is your pet on total parasite prevention?* Yes No If 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? Yes No Facts: 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? Yes No Facts: 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* MM slash DD slash YYYY Urinary Questionnaire:Have you noticed any changes in behavior since your last visit?* Yes No Explain:*Is your pet drinking more water than it used to? Yes No Urinating in larger or smaller volumes? Yes No which one Is your pet having urinary accidents in the house? Yes No Do they occur in specific locations? -WhereDo the accidents occur while your pet is sleeping? Yes No Have you noticed any straining when your pet urinates? Yes No Describe your pet’s urine colorIs your pet licking at his/her genitals? Yes No Is there any discharge from your pet’s genitals? Yes No Has a Vet diagnosed your pet with any previous urinary conditions/diseases? Yes No Explain:How was it treated/with what meds?Does your pet receive dry food? Yes No Brand Does your pet receive canned food? Yes No Brand Does your pet receive a homemade diet? Yes No Type: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? yes no Any recent changes in the home? yes no Type of litter used at your houseComments: - ————————————————————- Name* Patient Name Last Name Date* 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? Yes No Have you noticed any loss of vision or changes in vision? Yes No Does your pet have trouble seeing at night? Yes No Have you noticed any cloudiness to the eyes? Yes No Is one pupil a different size from the other? Yes No Have you noticed any rubbing at the eyes? Yes No Is one lid droopy? Yes No Which eye?Any sneezing, coughing, trouble breathing? Yes No Explain:Any discharge from the eye(s)? Yes No Please describe:Has your pet ever been tested for glaucoma? Yes No Has your pet ever been tested for dry eyes? Yes No Does your pet have cataract(s)? Yes No Any swelling of the eye(s)? Yes No Explain:Has your pet ever been seen by an Ophthalmology Specialist? Yes No If 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)? Yes No If yes, how is he or she acting?Does your pet have any behavior issues of concern? Yes No How long? Comments:Does your pet have any soiling issues, ie urinating, defecating, spraying? Yes No Comments:Any chewing or biting concerns? Yes No Comments: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? Yes No Comments:Does your pet have a dominant or submissive personality? Submissive urinator? Yes No Growler? Yes No Is your pet becoming more aggressive or irritable with age? Yes No Does your pet react negatively to thunderstorms ? Yes No Comments:Does your pet like Veterinarians? Yes No Comments:Is your pet nervous? Yes No Please list current medications ———————————————————— Name Patient Name Last Name Date MM slash DD slash YYYY Oral and Dentistry Questionnaire:What breed is your pet?Does your pet’s mouth have an odor? Yes No How often?Do you feed pet food that is approved by VOHC (has seal of approval of Veterinary Oral Health)? Yes No If so which one?Do you feed canned or dry food?Has your pet had a teeth cleaning and polishing before? Yes No When was the last one done?Were X-rays of the whole mouth taken? Yes No Have 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? Yes No Describe:Have you noticed any discoloration to any of the teeth? Yes No Describe:Have you noticed any odd shaped tissues or teeth in the mouth? Yes No Describe:Has your pet been diagnosed with any medical conditions or diseases in the past? Yes No Describe:Have teeth been extracted or received treatment in the past? Yes No Describe:Would you mind if we take photos of your pet to give you and also display in our “Wall of Smiles” photo collection? Yes No Initials:Comments: ———————————————————— Name* Patient Name Last Name Date* 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* 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 Brunfelsia Are any of these FOOD items in your house? Please check all that apply. Xylitol (found in most gum) Chocolate (esp. Dark) Ethanol (Beer, Liquor) Caffeine Are 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 Cannabinoids Are 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? Yes No If 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? Yes No Comments:Is there something about the body position that indicates pain? Yes No Comments:Have you noticed any behavioral changes? (i.e., grumpy, aggressive, depression). Yes No Comments: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? Yes No Comments: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? Yes No Have you noticed any changes in running and jumping? Yes No Comments:Have you noticed changes in the hair coat or grooming behavior? Yes No Comments:Any back pain, disc disease, arthritis, or any other painful disease diagnosed in the past? Yes No Describe:Comments: ———————————————————— Name* Patient Name Last Name Date* 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? Yes No Please list:Does your pet eat out of the garbage? Yes No Does your pet eat non-edible objects? Yes No What things does your pet try to eat?Does your pet vomit or regurgitate its food? Yes No How long after eating?