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Small Animal Medical History Questionnaire
This form should be filled out prior to your appointment and either saved and emailed to Dr. Weidenkopf (
michelleweidenkopf@gmail.com
) for her review prior to your appointment or printed out and brought to your appointment. Provide as much information as you can. This will save time and allow Dr. Weidenkopf to fully focus on the patient during your appointment.
Owner Name/email
Owner Address
Owner Phone Number
Patient Name
Patient Age, Gender, Color and Breed (if known)
Describe Your Concerns:
History of injuries or illnesses
Vaccination reactions and dates
Deworming product and date of last dose
Flea protection product and date of last dose
Heartworm protection product and date of last dose
Last dental procedure and date
What does your pet eat? Include food, medicines, pharmaceuticals, supplements, vitamins and minerals. How long has your pet been on each product and why are you using it? Also bring the product labels to your appointment if possible.
How long has your pet been with you? Describe what you know of his or her life before coming to you.
Does your pet travel well? How often do you travel with your pet? Is it for competitions, events, hiking, camping, training, daycare or boarding?
Describe housing situation. Indoor, kenneled outdoors, free roaming, electric fence, physical fence. How much time is your pet outside? How much alone time?
What other pets are in your household? How many and what species? What are the interactions between this patient and the rest of the pets? Is this pet dominant or submissive and why do you think so? Is the patient friendly, shy, aggressive, clingy with the other pets.
How does your pet interact with people? Strangers, men, women, children, etc. Is your pet friendly, shy, agressive, clingy, etc?
Is your pet vocal? When and what kind of vocalization (barking, whining, growling, etc)? How long is the duration?
Is your pet quick to get aggressive or over stimulated?
Do you see your pet sleeping? When does your pet sleep and where does he or she like to sleep? Does your pet's sleep seem normal to you in the amount and the depth?
Does your pet dream? How often? How can you tell your pet is dreaming? (vocalization, movement, etc)
What is your pet's energy level? (high, normal, low)
Does your pet enjoy playtime? What type of playing does he or she like to do? How much time is spent playing and exercising? What species does your pet like to play with or does he or she prefer to run around without engaging with another animal or person?
When you work on training your pet does he or she enjoy it? Is learning quick and can your pet concentrate on the lesson? Does your pet become anxious about the lesson?
Describe anything that makes your pet anxious. Also when and where it occurs. Include any fears, phobias, noises, sights, situations, etc. examples might be storms, gunshots, loud cars, crating, etc.
Does your pet find touch stressful? Where on their body? Does he or she react by pulling away, hiding, becoming mouthy, etc.
Does your pet tend to be hot or cold and when? ( check body parts such as ears, back and feet) Is there a season that your pet thrives or does poorly? Does he or she seek sun or shade at unexpected times?
Does your pet have drippy eyes? When? Is it watery or mucous? Describe.
Do you ever notice the white of eye or the mucous membranes becoming yellow or red in color? Does he or she have cataracts and how old was your pet when they were diagnosed with cataracts?
Has your pet ever been diagnosed with eye infections or allergies that are effecting the eye? Describe.
Does your pet tend to have dry or oily skin and hair coat? Has your pet had hives? Bug sensitivity? Is your pet itchy or does he or she rub on furniture, people, carpet, etc? Is the hair coat dull or flaky? Does a cut or scrap heal in a normal amount of time?
Has your pet ever had dental work? (cleaning under sedation, extraction, caps, etc) Does he or she have a history of dental problems? Do you brush or treat the teeth regularly and what do you use (brush, gel, dental bones, etc)
Does your pet seem to chew well? Does he or she have bad breath or salivate excessively? Does your pet's mouth seem dry? Describe.
Does your pet have any scars, swelling or scraps on their limbs and where are they located?
Describe your pet's appetite?
What doe your pet's poop look like? Is it soft, unformed, dry, etc? Are the piles excessively large or small? Does it vary or is it extremely smelly? Does your pet pass gas often? Is it smelly or loud? Describe.
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