Internal Medicine Questionnaire

How long have you owned your pet?

Where did you get your pet from?

What other pets are at home? Dogs/ Cats / Birds/ Exotics

Are any of them also sick?

Have there been any new additions to the household since the symptoms started?

Any visiting pets like fostering, rescues, dog-sitting?

Any recent boarding or doggy day care?

What kind of house do you live in?

Does your pet have access to outside?

Is your pet supervised outside?

Is there access to standing water?

Is there access to wildlife?

Has your pet traveled outside Alberta?

If yes, please indicate where and when (including any previous travel).

If the answer is yes, please let us know if it is increased, decreased, or the same, if decreased or increased please let us know what percentage compared to their normal (e.g., Fluffy is eating 50% of her normal), or frequency (Fluffy is vomiting twice per week).

Does your pet have any concerns with eating?

Does your pet have any concerns with drinking?

Does your pet have any concerns with vomiting?

Does your pet have any concerns with diarrhea?

Does your pet have any concerns with constipation?

Does your pet have any concerns with breathing issues (difficulty/ rapid breathing)?

Does your pet have any concerns with sneezing?

Does your pet have any concerns with coughing?

Does your pet have any concerns with nasal discharge?

Does your pet have any concerns with exercise intolerance and/or weakness/ collapsing episode?

Does your pet have any concerns with urination?

Has there been any vaginal or preputial discharge?

Has your pet been bred/mated? If so, when and how many times?

If your pet is an intact female, when was the last heat cycle?

Has there been any changes to your pet’s mobility? (Walking, running/ trotting, and jumping)

Does your pet have any concerns with their skin/coat?

Has your pet’s vision changed recently?

Has your pet’s hearing changed recently?

Does your pet have any concerns with their teeth?

Do you feel your pet is in discomfort/pain?

Have there been any changes with interest in daily activities and interaction with you?

Have there been any changes with interest in daily activities and interaction with other pets?

Have there been any behavioral concerns that impacts your pet?

Has your pet had any previous dentistry or other surgical procedures? If yes, when?

Were there any complications during the previous dentistry or other surgical procedures?

Internal Medicine Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

MAJOR PRESENTING PROBLEMS

OWNERSHIP AND OTHER ANIMALS

ENVRIONMENT AND TRAVEL

MEDICATIONS

VACCINES AND PREVENTION

FOOD AND SUPPLEMENTS

OTHER MEDICAL HISTORY

Internal Medicine Questionnaire

CLIENT INFORMATION

PATIENT INFORMATION

MAJOR PRESENTING PROBLEMS

OWNERSHIP AND OTHER ANIMALS

ENVRIONMENT AND TRAVEL

MEDICATIONS

VACCINES AND PREVENTION

FOOD AND SUPPLEMENTS

OTHER MEDICAL HISTORY

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