Pre-Visit Questionnaire for Integrative Medicine
Please fill out the following questionnaire with as much detail as possible so that Dr. Kate can learn all about your pet! This questionnaire will take about 10-15 minutes to complete.
Pet Name
Owner Name
First Name
Last Name
Date of Submission
-
Month
-
Day
Year
Date
Reason for Visit
Please describe your main concern(s)
Food and Drink
Rate the patient's CURRENT APPETITE:
1
2
3
4
5
6
7
8
9
10
1 Star = Not eating, 10 Stars = Strong appetite / eats well
Current diet:
Include brand information if possible
Current treats:
Include brand information if possible
Current eating schedule:
Amount of food (diet, treats, etc) patient eats in a 24 hour period:
Amount of water patient drinks in a 24 hour period:
How long has patient been on current diet?
Medications, Supplements, and Herbal Medicine
Current medications:
Include dose and frequency if possible. This does NOT include monthly preventatives, supplements, or herbal medicines. those details can be added below.
Current supplements:
Include brand information if possible
Current herbal medicines:
Include brand information if possible
Current heartworm preventative:
Most recent date given:
-
Month
-
Day
Year
Frequency of use:
Year-round
Seasonal
Not up to date
Unsure
Current flea/tick preventative:
Most recent date given:
-
Month
-
Day
Year
Frequency of use:
Year-round
Seasonal
Not up to date
Unsure
Energy, Temperature Preferences, and Sleep
Rate the patient's ENERGY LEVEL:
1
2
3
4
5
6
7
8
9
10
1 Star = No energy, 10 Stars = Very energetic
Describe the patient's daily exercise regimen:
The patient prefers:
Warm places (blankets, beds, sun, heaters)
Cool places (til or wood floors, drafty sites, shade)
No temperature preference
The patient sleeps through the night without getting up:
Yes
No
Unsure
Current Patient Condition
Rate the patient's VISION:
1
2
3
4
5
6
7
8
9
10
1 Star = Blind, 10 Stars = Sees well
Rate the patient's HEARING:
1
2
3
4
5
6
7
8
9
10
1 Star = Deaf, 10 Stars = Hears well
Rate the patient's LEVEL OF ITCHINESS:
1
2
3
4
5
6
7
8
9
10
1 Star = Not itchy, 10 Stars = Extremely itchy
If itchy, please describe times of the day/time when patient scratches:
Describe any skin conditions (lesions, rashes, lumps or bumps) including location(s):
Frequency of bathing:
Shampoo used:
Include brand information if possible
How the patient has been feeling:
*Yes
No
*If yes, please describe:
Limping / lameness
Vomiting
Gagging
Drooling
Diarrhea
Constipation
Accidents in the house
Burping
Flatulence
Coughing
Sneezing
Nasal discharge
Eye discharge
Patient Personality
What is the patient's passion in life?
How does the patient feel about other animals?
Please choose the adjectives that MOST CLOSELY reflect the patient's personality:
Supercharged
Hyperactive
Laid back
Sweet
Kindhearted
Aloof
Disciplined
Cautious
Fearful
Commanding
Bossy
Leader of the pack
Submit
Should be Empty: