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| 780-570-9999
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Menu
Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Orthopedic Foundation for Animals (OFA)
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Internal Medicine Questionnaire
Internal Medicine Questionnaire
Step
1
of
6
16%
Date
*
MM slash DD slash YYYY
Client Information
Owner's Name
*
First
Last
Primary Phone Number
*
Email Address
*
Patient Information
Pet's Name
*
Date of Birth
*
MM slash DD slash YYYY
Breed
Gender
*
Female
Female Spayed
Male
Male Neutered
Do you consent to having your pet included in educational and promotional material used on websites, social media and in professional presentations? This could include photographs, diagnostic images, patient medical information, and pet's first name.
*
Yes
No
Internal Medicine Questionnaire
Major Presenting Problems
In just a few words please indicate the problem you are coming in for:
*
What signs did you first notice?
*
When were your pet’s symptoms first noticed?
*
What has been done (medications/ procedure/ diet) or tried by your veterinarian for this condition?
*
Do you have a video (preferred), image of the event, or a log that you would like to share?
If your pet has seen multiple veterinarians in the past or been seen through the emergency services, please list the clinics so that we could have all the records for review.
What are your expectations from this appointment
Further diagnostic work up – if anything particular has been mentioned to you
Medical management options
Unsure
Ownership and Other Animals
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?
Environment and Travel
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 of Alberta? If so where and when? (Include previous travel etc. as well)
Medications
Is your pet taking any medications (Please include drug name, product name, concentration, frequency and since when)?
Is your pet allergic or intolerant to medications?
Vaccines and Prevention
Is your pet up to date on vaccines?
Is your pet up to date on prevention? If so which ones? When did they receive them last?
FELV/FIV Status? (Feline patients only)
Postive
Negative
Unsure
Food and Supplements
What diet does your pet eat (Brand, wet or dry, how much and how often)?
Have there been any changes to the diet? If so when
What treats does your pet eat (Brand, wet or dry, how much and how often)?
What supplements does your pet take (Brand, wet or dry, how much and how often)?
Does the diet include raw food?
Does the include grain free diets?
Is your pet allergic or intolerant to any food?
Based on your evaluation is you pet ‘s body condition thin, ideal or heavy?
Other medical history
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
Where there any complications during the previous dentistry or other surgical procedures?
