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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 (drmichelle@holisticveterinaryoptions.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 during your appointment and allow Dr. Weidenkopf to fully focus on the patient.
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Client Name
Client full mailing address
Client email address
Client phone number
Patient name
Age, gender, breed(s) color(s) and weight
Describe Your concerns. What do you hope to help your pet with?
What treatments have been used to address this condition? What was the response to treatment?
History of your pet's injuries or illnesses. If the history is too complicated please briefly summarize here and make your medical records available to share with me.
Is your pet vaccinated? How frequently is it done? Which vaccines are used? Have there been any vaccination reactions? If so please list date of reaction, vaccine type and describe the reaction.
Deworming product and date of last dose. Do you have a stool sample checked annually?
Flea protection product and date of last dose.
Heartworm protection product and date of last dose.
Is your pet exposed to pesticides/herbicides? ( (Common places of exposure to Round-up or other chemicals would be from walking on treated lawns, gardens, farm fields, golf courses and railroad right-of-ways.)
Last dental procedure and date
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.
Has your pet ever had dental work? (cleaning under sedation, extraction, caps, etc) Does he/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)
What does your pet eat? Include food, chew bones/rawhides, dental chews, treats, medicines/ pharmaceuticals including over-the-counter or human medications like aspirin, supplements and vitamins/minerals. How long has your pet been on each product and why are you using it? Number of feedings per day and amount fed per day. Also bring the product labels to your appointment if possible. Will you need refills on any medications you are currently using?
Describe your pet's appetite? Have you had any issues with vomiting or diarrhea? Is your pet's appetite out of control or very finicky?
What is your pet's weight? Is this a healthy weight for your pet? Do you think he/she needs to gain or lose weight? Has your pet gained or lose weight in the past year?
Does your pet drink a lot of water? If so does it happen in frequent sips or high volume intake?
When your pet defecates what does it 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.
Does your pet need it's anal glands expressed frequently? How often is it done?
Do you have any issues with litter box usage? Are there other cats in the household and  how many? How many litter boxes do you have and where are they located? Are the boxes covered or automatically cleaned?
What type of cat litter do you use? (clumping, scented or unscented, clay, paper, etc) Does the cat use the boxes consistently? How often are the boxes cleaned?
Does you pet cough? If so, when and how frequently? If yes, is it a soft or forceful cough? A wet or dry cough? Does the cough get worse with exercise or certain weather or environments? Does your pet have a collapsing trachea? Does your pet have any breathing issues?
Does your pet have drippy eyes or nose? When? Is it watery or mucous? Is it clear or colored? What color is the liquid?
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? Did it effect one or both eyes? Describe.
Does your pet have a history of ear infections? Do the ears smell bad or need to be cleaned frequently? Is it one (left or right) or both?
Does your pet tend to have dry or oily skin and hair coat? Does he/she lick or chew at self, groom excessively or have hot spots? Has your pet had hives or 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 your pet have dandruff? If so describe. How frequently is your pet bathed?
Does your pet have any scars, swelling, scrapes, lumps or bumps on their limbs or body and where are they located? Does a cut or scrape heal in a normal amount of time? Is your pet showing any signs of physical pain like limping, stiffness or soreness? Do you have your pet's nails trimmed often? Is it easy or difficult to do?
How long has your pet been with you? Describe what you know about his/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 the housing situation. Indoor only, kenneled or kept outdoors, free roaming, electric fence, physical fence. How much time is your pet outside? If you have a cat is it indoor only or indoor/outdoor? How much alone time? Is he/she happy or anxious when alone?
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 or clingy with the other pets?
How does your pet interact with people? Shy, aggressive, friendly, playful?
Is your pet vocal? When and what kind of vocalization (barking, meowing, howling, whining, growling, etc)? How long is the duration?
Is your pet quick to get aggressive or overstimulated?
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) More lethargic than usual? Do you have any concerns about the energy level?
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 does your pet enjoy it? Does he/she learn quickly and 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, separation anxiety, 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). Does your pet seek heat or air conditioning vents? Prefer tile floors or carpet? Hard floors or a soft bed? Does your pet pant excessively and if so does it seem to be heat or stress related? Is there a season that your pet thrives or does poorly? Does he or she seek sun or shade at unexpected times?
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