River Road - Patient Consult Questionnaire

1
Patient Consult Questionnaire-
- **Pet's Name**
- **Your Full Name**
- **Appointment Date**
2
- **Your phone number**
- **Alternate phone number**
- **Your email address**
- **Reason for appointment?**
3
*How is your pet's...*
Normal
Abnormal
- **Appetite?**
**If abnormal, please elaborate:**
Normal
Abnormal
- **Water intake?**
**If abnormal, please elaborate.
Normal
Abnormal
- **Urination?**
**If abnormal, please elaborate.**
Normal
Abnormal
- **Bowel Movements?**
**If abnormal, please elaborate.**
4
Yes
No
- **Has your pet been vomiting?**
**If yes, please provide detail.**
Yes
No
- **Any recent change in activity/energy levels?**
**If yes, please provide detail.**
- **Has your pet been scratching? If yes, please provide detail.**
5
- **What heartworm prevention is your pet currently taking?**
**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
6
- **What flea and tick prevention is your pet currently taking?**
**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
7
- **What food(s) does your pet eat, and how much/how often are they fed? Any treats?**
8
- **What medications and/or supplements is your pet taking? Do you need refills?**Please provide prescription strengths and quantity/frequency given if possible.
9
- **Is your pet indoor, outdoor, or both? Please elaborate.**
- **To what other animals is your pet exposed?**
- **Are there any behavioral issues you would like to discuss?**
10
- **Are there any other general health concerns you would like to discuss?**
11
- **Do you need advice on stress-free transport or medication?**
Yes
No
Should be Empty: