Pre-visit Questionnaire | Animal Medical New City

Is this your first visit to Animal Medical of New City?

Yes

No

Is this a scheduled follow up appointment for a problem we have seen your pet for within the past month?

Yes

Yes, this is a surgery/procedure drop off.

No

Pet Owner and Pet Name

First Name: *

First

Last Name *

Last

Pet's name *

Address

Address 1 *

Address 2

City/Town: *

State/Provence *

Zip/Postal Code:

Primary Phone *

Secondary Phone:

Email

We only use your email to help us locate medical records and to send you your pet's diagnostic results.

Confirm E-Mail:

What is your preferred method of communication?

Text me at my primary phone number.

Email me at the email address listed above.

Call me at the primary number listed.

I prefer face-to-face communication when I'm at your office.

Phone

Though we have your phone on file, please list it again here to assist us with finding all of your pet's medical records.

Do you have pet insurance? If so, which company?

Do all of your pets receive year round flea, tick, and heartworm prevention?

Yes

No

Please explain how often you do administer and if not why?

Which of the following parasite preventatives do you administer? Select as many as are appropriate.

Please list when the last dose was administered

If you have a cat, does he or she go outside?

Yes

No

Medical History

Please use the buttons below to tell us more about how your pet is behaving and feeling. At the end of this section, you'll be able to explain your answers in more detail.

What is the reason for your pet's visit with us today?

How is your pet's appetite?

Good

Fair

Poor

What have you been feeding your pet? Check all that apply.

Dry Food

Canned Food

Table food

OtherOther

Please describe the brand name, volume of food and frequency that you feed.

Describe the change in your pet's appetite. When did your pet's appetite worsen? Are there other aspects of your pet's appetite you would like us to know about?

Has your pet had any vomiting recently?

Yes

No

Please describe the frequency and contents of the vomitus.

How soon after eating does the vomiting occur?

Has your pet had any diarrhea recently?

Yes

No

Choose the closest description that fits your pet's stool consistency

1-Very hard, dry and segmented

2-Firm but not hard, pliable and easy to pick up

3-Soft, not segmented, barely holds form when picked up

4-Very Soft, soggy, loses form when picked up

5-Soft serve consistency, makes a pile and difficult to pick up

6 - Has texture but no defined shape, pudding consistency

7 - No shape or texture, liquid consistency

Have you noticed any blood or mucus in the stool

Yes

No

Please describe the consistency, volume, frequency and note if there is any blood or mucus is in the stool.

Has your pet had prior episodes of diarrhea?

Yes

No

Please describe it's consistency, volume, frequency and note how and if prior episodes are different from this one.

Has your pet been sneezing, coughing, or had difficulty breathing?

Yes

No

Please describe the duration, frequency, situation or time of day when the condition seems to occur or get worse?

Have you noticed a change in thirst or urination?

Yes

No

Please provide us more information on your pet's change in thirst or urination. Volume of water consumption, Volume of urine, frequency of urination, color, presence of blood in the urine, and/or straining are all important details for us to know.

Inappropriate urination is often linked to significant household changes, changes in pet ownership, the addition of new pets, etc. Please describe where the pet is urinating inappropriately or any other changes to your household that your believe are noteworthy.

Have you noticed any lumps or bumps or changes in ones that we have already identified?

Yes

No

Please tell us the location of the mass(es), when you first noticed it(them) and if there has been any recent change in size.

Have you removed any fleas or ticks from your pets recently?

Yes

No

Dermatology History

Does your pet itch, lick, chew, or bite themselves excessively and appear uncomfortable?

Yes

No

When was this first noted?

Did a rash precede the onset of itching and if so what part of the body was it first recognized?

Does your pet itch intermittently or constantly?

Intermittently

Constantly

It's complicated

Has this been an issue previously? If so is it seasonal or year round?

Has your pet had any related hair loss? Use the space below to explain where the hair loss is and other information related to it that you believe is important.

Is the itching worse and any particular time of the day?

Is the itching worse when outdoors or indoors?

Are other pets or family members in the household experiencing skin issues?

Yes

No

If you answered 'yes' to the above question, please explain here.

What medications have you used to treat your pet for this condition and were any of the helpful?

Do you have forced hot air or radiant heat in your home?

Please describe the type of flooring you have in your home and if any of these were recently installed; wall to wall carpeting, area rugs or wood floors only.

Please list any recent diet/treat changes, and all food fed not listed above.

Has your pet every been placed on a food elimination trial for food allergies? If so what food did you feed and was it successful?

Is your pet exposed to tobacco smoke, burning candles, incense or carpet fresheners?

Do you use insecticides in your home or yard?

Do you have other pets at home? Can you please list their names and what species they are?

Do any of your pets spend any time outdoors and if so for what length of time?

Please list any and all prescriptions and over the counter products you use on your pet on a regular basis.

Other concerns

Use this field to describe any of your above answers or to give us more information on your pet's health

Follow up Medical History

Please list any changes in diet in treatment prescribed and why

Please describe any additional concerns you may have

We look forward to seeing you at your pet’s upcoming visit.

Pet Owner and Pet Name

Address

Medical History

Dermatology History

Follow up Medical History