PERSONAL DETAILS Name * First Name Last Name Email * Phone Number * Address * Pets Name * HISTORY CHECKLIST What is the primary reason you are seeking medical advice today? Please be as descriptive as possible * If this reason above is to check a 'lump' please describe exactly where the lump is, how many there are and what size they are. * Does your pet have any other problems that are concerning you? * How long has your pet had this primary problem? * Was the onset of signs rapid, gradual or intermittent? * Rapid Gradual Intermittent Has the problem improved, worsened or not changed over time? * Improved Worsened Not changed Has a similar problem happened in the past? * Yes No Have you sought advice from another clinic for this problem? * Yes No Have any medications and/or treatments been administered for this problem? And what effect did they have? * Has there been a change in attitude or behaviour in your pet with this problem? If so, how? * Yes No If you selected yes above please explain with as much detail as possible. * Has the problem affected your pets ability to exercise and by how much? * How is your pets appetite? Increased, decreased or normal? * Increased Decreased Normal What is your pets current diet. * What snacks or treats do they have? * How often are they fed? * Have you noticed an increase or decrease in weight? * Increased Decreased Normal Has your pet had any vomiting or diarrhoea? * Vomiting Diarrhoea No Change If your pet has one of the symptoms described in the previous question please describe how often this occurs. How many times a day? Any change in water consumption? Increased or decreased? * Increased Decreased No Change Any change in urine habits? For example, frequency, straining/difficulty, colour, odour, spraying/marking or ‘accidents’. * Has your pet had any of these signs? * Coughing Sneezing Itching New Swelling/markings Runny nose Runny eyes Abnormal breathing None of the above When was your pet last treated for fleas and with what? * Are you giving your pet any other supplements or medication? * Thank You!We appreciate you taking the time to fill out the form. Your details have been submitted, and we’ll be in touch soon. If you need further help, please call reception on 09 521 1457.RegardsThe Kohi Vet Team PRE CONSULTATION QUESTIONNAIRE
