Elkridge Animal Hospital
Pre-Exam Questionnaire
Owner's Name
*
First Name
Last Name
Pet's Name
*
My pet is a
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Dog
Cat
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Pre-Exam Questionnaire
Please take a few minutes to read through and answer the following questions to expedite your appointment check-in process. If you have multiple pets checking-in, please submit a questionnaire for each pet. There will be an option after submitting the questionnaire to complete a second form for your next pet.
Do you have any specific concerns or any questions for the veterinarian to address during your exam?
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Yes
No
Please select any changes in your pet's behavior:
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Normal/ No change
Lethargic
Aggressive
Increased Energy
Vocalization
Hiding More
Other
Please select any changes in your pet's appetite:
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Normal/ No change
Increased
Decreased
Not Eating Anything
Difficulty Chewing
Other
Please select any changes in your pet's water intake:
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Normal/ No change
Increased
Decreased
Not Drinking at All
Other
Please select any changes in your pet's urination:
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Normal/ No change
Increased
Decreased
Bloody
Straining
Inappropriate
Other
Please select any changes in your pet's urination:
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Normal/ No change
Increased
Decreased
Bloody
Straining
Inappropriate, not using the litter box
Unknown, since they go outside
Other
Please select any changes in your pet's defecation:
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Normal/ No change
Diarrhea/ Soft stool
Bloody
Straining
Inappropriate
Other
Please select any changes in your pet's defecation:
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Normal/ No change
Diarrhea/ Soft stool
Bloody
Straining
Inappropriate, not using the litter box
Unknown, since they go outside
Other
Are they an "indoor" or "outdoor" cat?
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Indoor strictly
Indoor only; however, they are known to sneak outside on occasion
Indoor only but another feline housemate goes outside
Indoor but does interact with other cats through window screen
Indoor/ outdoor
Outdoor mainly
Other
Is your pet experiencing any sneezing, coughing or vomiting?
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Normal/ None of the below
Sneezing
Coughing
Vomiting
Please check if your pet is experiencing any of the following:
Sneezing
Coughing
Eye/ Nose Discharge
Limping
Trouble with Mobility
Wound/ Abrasion
Lumps/ Masses
Chewing/ Scratching/ Licking at Skin
Hair Loss/ Skin Irritation
Discharge/ Odor from Ears
Shaking Head/ Scratching Ear(s)
Odor from Mouth
Vomiting
Dietary Change
Weight Gain or Loss
Other
How long has your pet been experiencing symptom(s)?
Do you know of any injury or trauma that could have caused this injury? If so, please explain:
Has your pet been seen previously for this issue or a related issue? If so, approximately when?
Which leg are they limping on?
Front left
Front Right
Rear left
Rear right
Unable to determine
Please describe contents of the vomit and frequency:
i.e. food, bile, hairball
Location of mass or wound:
Head
Front leg
Rear leg
Chest
Abdomen
Tail
Other
Which side of the body is the mass or wound on?
Left
Right
Along back
Along abdomen
Please provide further details regarding your pet's symptoms if you are able:
Include timeline of symptoms and frequency
Does your dog go to boarding facilities, dog parks, doggie daycare, or any other place where they would be in regular contact with other dogs?
Yes
No
Other
Do you or your dog frequent areas where ticks are likely? i.e. tall grassy or wooded areas
Yes
No
Other
Are there any other concerns or questions you would like the veterinarian to address today?
Do you have a picture you'd like to share to further illustrate your pet's symptoms?
Yes
No
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Medication Questions
Is your pet currently on any medications, other than routine flea/tick or heartworm preventatives?
*
Yes
No
Please list your pet's current medications:
Please feel free to abbreviate as needed
What medications were given today and at what time?
Is your pet on heartworm prevention?
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Yes
Not currently; I've missed some doses and need to restart
No; I need more information about heartworm disease
What type of heartworm preventative do you use?
Proheart12 Injection
HeartGard Plus or similar once monthly oral product
Revolution or Revolution Plus
Other
Is your pet on heartworm prevention?
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Yes, we use a topic product such as Revolution
Yes, we use an oral product such as HeartGard for Cats
No; I need more information about feline heartworm disease
Other
When was the last dose of heartworm preventative given?
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An approximate date is fine
Is your pet currently on a flea and tick preventative?
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Yes
No
What type of flea and tick preventative do you use?
NexGard
Revolution or Revolution Plus
Frontline or similar topical OTC product
Other
Is your pet on a flea and tick preventative?
Yes, we use Revolution/ Revolution Plus or a similar prescription product
Yes, we use Frontline or similar topical OTC product
Yes, we use a flea/ tick collar
No
Other
Do you need a refill of any medications?
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Yes
No
What medication(s) do you need refilled?
Please list the medication's name (abbreviate as needed!), current dosage you are giving, and quantity being requested.
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