Kohi Veterinary Clinic
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PRE CONSULTATION QUESTIONAIRE
Full name
Email address
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?
Increase
Decrease
No change
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 swellings/markings
Runny nose
Runny eyes
Abnormal breathing
None of the above
null
When was your pet last treated for fleas and with what?
Are you giving your pet any other supplements or medication?
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