Internal Medicine History Questionnaire
Name
First Name
Last Name
Pet's name
Primary reason for Internal medicine consultation:
Does your pet have other concurrent conditions that are being currently treated?
Does your pet have any major pertinent past historical medical problems (such as major surgery, hospitalization, emergency visits)?
Are you aware of any allergic or adverse reactions to any previous medications or treatments?
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What is your pet's current primary diet?
Rows
Brand Name
Flavor
Feeding style (free choice vs meal basis)
Amount fed
Dry food
Free choice
Meal basis
Can food
Free choice
Meal basis
Other
Free choice
Meal basis
How long has your pet been on the current diet?
Please list any previous diets
Does your pet get any treats or table food?
Rows
Yes or no
Examples & amount given
Frequency
Treats
Yes
No
Everyday
once a week
once a month
occasional (hard to tell)
Table food
Yes
No
Everyday
once a week
once a month
occasional (hard to tell)
Is your pet's appetite currently normal?
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Background/Environment
When and where did you attain your pet?
Have you traveled anywhere outside the Central Florida in the past 1yr with your pet?
Do you have any other pets at home?
Dogs
Does your pet have free access outside unsupervised (i.e backyard, during camping trips, running trails, etc)?
Cats
Is your cat indoors or outdoors?
Please Select
Indoors
Outdoors
Both
Has your cat been tested for Feline leukemia virus/Feline immunodeficiency virus (Felv/FIV)?
Please Select
Yes (within the past 6 months)
Yes (but unsure when)
No
Not sure
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Current symptoms
What current symptoms does your pet exhibit? (please state yes or no; if yes- when the problem started, progression of symptoms and if there was any response to any treatments-positive or negative)
Rows
Yes or No
Coughing
Yes
No
Sneezing
Yes
No
Changes in thirst/urination
Yes
No
Vomiting
Yes
No
Diarrhea
Yes
No
Changes in appetite
Yes
No
Weight loss
Yes
No
Additional questions on current symptoms
Coughing
When did coughing start?
Since coughing started, the symptoms have been:
Rapidly progressive
Mildly progressive
Unchanged
Other
Cough characteristics
Rows
Yes or No
If Yes, rate on scale of 1-10
(1=almost no symptoms or rare occurrence)
Coughing is productive
Goose honk is present
Respiratory distress is present
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
Sneezing or nasal discharge
When did sneezing or nasal discharge start?
Since sneezing or nasal discharge started, the symptoms have been:
Rapidly progressive
Mildly progressive
Unchanged
Other
Sneezing/nasal discharge characteristics
Rows
Yes or No
If Yes, rate on scale of 1-10
(1=almost no symptoms or rare occurrence)
Sneezing is productive or nasal discharge is present
Congestion is present
Respiratory distress is present
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
Abnormal thirst or urination
When did abnormal thirst or urination start?
Please select the option that best represents your pet's current thirst or urinary habits.
Increased thirst
Increased urination (large puddles)
Increased urination (small puddles)
Abnormal urination characteristics
Rows
Yes or No
If Yes, not if present at a specific time (i.e beginning of urination or end of urination)
Straining to urinate
undefined
Painful or having difficulty urinating
undefined
Blood is present
undefined
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
Changes in appetite
When did you note that there is a change in appetite?
Is your pet's appetite increased or decreased?
Which of the follow best describes your pet's current intake?
Please Select
25% of normal
50% of normal
75% of normal
Changes in appetite characteristics
Rows
Yes or No
Is there any difficulty in swallowing (or multiple attempts to swallow)?
Yes
No
Have you seen any signs dropping food when chewing?
Yes
No
Have you seen any coughing or hacking when eating?
Yes
No
Weight loss
When did you notice that your pet has been losing weight?
Since weight loss has been noted, the symptoms have been:
Rapidly progressive
Mildly progressive
Unchanged
Other
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
Diarrhea
When did diarrhea start?
Since diarrhea started, the symptoms have been:
Rapidly progressive
Mildly progressive
Unchanged
Other
How would you best describe the consistency of the diarrhea?
Please Select
watery/liquid diarrhea
soft/unformed (cow pie consistent)
soft formed
combination
Diarrhea characteristics
Rows
Yes or No
Mucus present?
Yes
No
Blood present?
Yes
No
Does the stools every look "dark- black/tarry" in appearance?
Yes
No
Is there any difficulty defecating?
Yes
No
Has the frequency of defecation increased?
Yes
No
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
Vomiting
When did vomiting start?
Since vomiting started, the symptoms have been:
Rapidly progressive
Mildly progressive
Unchanged
Other
Vomiting characteristics
Rows
Yes or No
Is the vomiting associated with abdominal effort?
Yes
No
Nausea (lip-smacking, drooling) is present?
Yes
No
Does the vomitus ever contain any blood?
Yes
No
Does the vomitus ever appear like “coffee ground"?
Yes
No
Does vomiting occur immediately after eating?
Yes
No
Vomiting characteristics
Please Select
Bile (yellow liquid)
Foam or white liquid
Food
Other:
Has there been any POSITIVE responsive to any treatments so far?
Has there been any NEGATIVE responsive to any treatments so far?
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Please list all current medications:
Rows
Name of Medication
Strength (mg or mg/mL)
Frequency (ie every 8 hours, 12 hours, 24 hours)
When was the medication started (approximate date)
When was the last time mediation was administered
1
2
3
4
5
6
Does your pet currently take any heartworm, flea/tick preventative medications?
If yes, please list the name of the medication.
Is your pet on any current supplements or over-the-counter medications?
Has your pet been on any previous medications that he/she is no longer on currently?
Is your pet up to date on rabies vaccines?
Yes
No
Is your pet current on other recommended vaccines?
If yes, please list other current vaccines.
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Please let us know if you have any additional concerns.
Please upload any records or documents that may be important for us to review. If you like to share a picture of your pet for us to attach to our chart, you are welcome to upload the picture here as well.
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