New Client Questionnaire - Deafness
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
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
If your pet is insured which company do you use?
What is your pet's policy number?
Name of local vet clinic?
What is the main problem?
At what age was the hearing loss first noticed?
How quickly did the hearing loss occur?
Suddenly
Gradually
Has there been a history of head trauma?
Yes
No
Have there ever been any previous ear problems?
Yes
No
Ear Infections
Has your dog had an ear infection?
Is one ear affected or both?
Left
Right
Both
Is one worse than the other?
Left
Right
Both the same
Approximately how many times has your pet been treated for ear infections?
Have any of the following been observed?
Ear discharge
Head shaking
Scratching the ear
Rubbing the ear
Head tilt
Haematoma
Loss of balance
Eye movement
Odour
Foreign object
Grass seed
Other
Do you know of any relatives of this pet that have ear problems?
Yes
No
Behaviour Symptoms
Have any of the following been observed?
Disorientation
Aggression
Poor coordination
Disobedience
Poor recall
Depression
Slow to respond
When called does your pet look to one side?
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Home Details
Do you have any other pets?
Yes
No
If so, how many?
Please estimate how much time your pet spends:
Indoors
%
Outdoors
%
Does your pet swim?
Yes
No
If so, how often & where?
Where does this pet sleep?
What room?
What type of bedding?
What type of flooring do you have in your house?
Where do you walk your pet and how often?
Bathing
Does bathing:
Help
Worsen
Make no difference
What type of shampoo are you using?
How often do you bath your pet?
Weekly
Monthly
Rarely
Other
How often do you clean your pets ears?
Weekly
Monthly
Rarely
Other
What technique do you use?
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Medication
Please give the name and dose of medication/s given
Ear Drops
Name / Dose & Date Last Given
Ear Cleaner
Name / Dose & Date Last Given
Tablets
Name / Dose & Date Last Given
Ointments / Lotions
Name / Dose & Date Last Given
Injections
Name / Dose & Date Last Given
Rinses
Name / Dose & Date Last Given
Is your dog on heartworm treatment?
Yes
No
What type of heartworm treatment is being used?
General Health
Has there been any?
Vomiting
Diarrhoea
Mucous stools
Lethargy
Increased water intake
Increased appetite
Weight gain
Weight loss
Weakness
Does your pet have any other illness, if so please specify what medicines are being prescribed?
What do you think could be the cause of the skin problem?
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