Bee and Wasp Questionnaire
Clinic you wish to attend
Murdoch
Vet24
Patient Name
*
Owner's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Please tell us how you found us:
*
Veterinary referral
Online search (Google, etc.)
Social media
Word of mouth
Other
If your pet is insured, which company do you use?
What is your pet's policy number?
Do you consent to us posting images of your pet on social media?
Does your pet have a social media account?
What is your pets social media account name?
example@example.com
Name of local vet clinic
What is the main problem?
When did the anaphylaxis occur?
How severe was your pet’s anaphylaxis:
MILD: Redness; hives; facial swelling; itch
SEVERE: Collapse, unresponsive, urinary or faecal incontinence, paleor blue gum colour
MODERATE: Difficulty breathing, wheezing, vomiting diarrhoea,drooling, disorientation
EXTREME:Required blood transfusion; >1 night ofhospitalisation
How many times was your pet stung during this episode?
Please describe the events leading up to the anaphylaxis event?
Was the cause of the anaphylaxis known (ie insect stinger was found)
Yes
No
If yes: What was the cause and where on the body was your pet stung?
Are you aware of your pet suffering from previous insect stings? If yes: a) When was your pet last stung? b) How many times has your pet been stung in the past? (please list approximate dates if known) c) How severe was the reaction from the previous sting? Has your pet been sent home with any medications?
How long does you pet stay:
Indoors:
%
Outdoors:
%
Does your pet have any allergy symptoms (eg paw licking, scratching, head shaking, scooting on bottom etc) If yes, please list
Current Diet:
Does your pet have any other known medical conditions? (eg allergies, heart condition, frequent vomiting, diarrhoea etc) If yes, please list
Current Flea Treatment
Is your pet on any other medication? If yes, please list
Do you consider your pet to be healthy at present? If yes, please explain
Submit
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