JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Consultation Questionnaire
Completing this form ensures we have a detailed and standardised clinical history to assist us in better understanding your pet's current problem/s as well as overall health.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name:
*
your first name
Your answer
Surname:
*
your surname
Your answer
Pet's name:
*
Given name ONLY
Your answer
Pet's Age:
*
In years and months, or in weeks if less than 6 months old
Your answer
Species:
*
Dog
Cat
Other:
Breed:
*
Your answer
Sex:
*
Male
Male Desexed
Female
Female Desexed
Weight (kg):
*
Your answer
Time you've had your pet
*
How long have you had your pet?
entire life i.e. since a pup or kitten < 10 weeks old
Other:
Other Animals?
*
Excluding the patient on this form do you have any OTHER dogs or cats at home? (You may select more than one answer)
NO
1 dog
2 or more dogs
1 cat
2 or more cats
Required
Daily diet:
*
Your pet's typical daily diet (if a commercial diet specify brand/s) including any treats:
Your answer
Appetite change:
*
Has your pet's appetite changed recently?
No
Eating more
Eating less
Altered Thirst:
*
Has your pet's thirst changed recently?
No
Drinking more
Drinking less
Weight change:
*
Has your pet's weight changed recently?
No
Gained weight
Lost weight
Previous health problems:
*
Has your pet had any previous health problems? If no previous problems write NO
Your answer
Health problems in relatives:
*
Are you aware of any health problems in litter mates or close relatives?
Your answer
Surgical history:
*
List all previous surgeries excluding desexing (neutering) & approximately when they were performed, or if no previous surgeries answer NONE.
Your answer
Blood Tests:
*
Have any blood tests been performed within the past six months?
No
Not sure
Yes, within last week
Yes, within last 2 weeks
Yes, within last month
Yes, within last 3 months
Yes, within last 6 months
Pre-injury activity:
*
Indicate your pet's level of activity BEFORE injury. Select as many options as you wish.
House and garden
lead walking
off-lead exercise
vigorous running
duration <10 minutes daily
duration 10 - 20 minutes daily
duration 20 - 45 minutes daily
duration 45 to 90 minutes daily
duration > 90 minutes daily
Other:
Required
Current activity:
*
Indicate your pet's CURRENT level of activity (since injury/onset of problem). Select as many options as you wish.
Cage confinement
Room confinement
House confinement
Garden confinement
lead walking
off-lead exercise
vigorous running
duration <10 minutes daily
duration 10 - 20 minutes daily
duration 20 - 45 minutes daily
duration 45 to 90 minutes daily
duration > 90 minutes daily
Other:
Required
Nail scuffing:
*
Does your pet ever scuff (scrape) their nails on the ground whilst walking or running
No
Occasionally
Often
Always
Not Sure
Pain & Vocalising:
*
Does your pet ever cry out in pain (e.g. yelp), either currently or in the RECENT past; if YES please describe yelping events.
Your answer
Primary Problem:
*
Choose the option that BEST describes your pet's CURRENT problem. If you are unsure please select "Not Sure".
Cruciate ligament tear (unstable knee)
Patellar luxation (dislocating knee-cap)
Lameness (limping)
Hip Dysplasia
Fracture (broken leg, jaw, pelvis etc)
Fully dislocated (luxated) joint
Partially dislocated (subluxated) joint
Ruptured or prolapsed DISC in spine
Spinal Fracture (i.e. neck or back fracture)
Non-specific Neurological problem
Multiple problems NOT including fractures
Not sure
Other:
Next
Clear form
Never submit passwords through Google Forms.
Forms
This form was created inside of BoneVet.
Report Abuse
Terms of Service
Privacy Policy
Help and feedback
Contact form owner
Help Forms improve
Report