Internal Medicine Questionnaire Recheck

Internal Medicine Questionnaire

**Recheck**
Dear Pet Parent:

Since this is a recheck exam, the focus of these questions will be based on your pet's current condition. Please make sure you share any challenges and successes you are having so I can make sure to integrate this into my recommendations. Thank you in advance for sharing this information and helping me help you and your pet!

Sincerely,

Dr. Hammer
Your pet's name
Pet parent's name

First NameLast Name
Please share a general updates as to how {yourPets} is doing and any concerns that you would like to share?

Clinical Signs at Home

This section will review everything you are seeing at home. Some may no apply to your pet. Those that do, the more detail the better. Colors, frequency, time of day, left or right side....anything you can think of.
How is your {yourPets}'s appetite/ interest in food?*
Describe (note any changes related to medications, etc)
What is {yourPets} currently eating?*
How are {yourPets}'s bowel movements?*
If abnormal describe further including color, consistency, frequency, larger or smaller amounts than normal, mucus, blood, straining etc.
Here is a helpful link with descriptions and grading schemes for bowel movements in cats and dogs. Purina Fecal Scoring Link....
Is {yourPets} vomiting or regurgitating?*
Vomiting involves an active abdominal component (heaving, retching). Regurgitation is often passive where food or liquid appears to just 'fall' out {yourPets}'s mouth.
If abnormal describe further including frequency, relation to eating, vomiting versus regurgitation, changes with diet or medication etc.
How is {yourPets}'s weight?*
If there have been weight changes, describe further including relationship to diet changes, medications, changes in appetite etc.
How is your {yourPets}'s thirst?*
If abnormal, describe further (note any changes related to diet, medications tried etc.)
How is your {yourPets}'s urination?*
If abnormal, describe further including changes in color, larger or smaller volumes, frequency, accidents in the house, leaking, changes related to medications or diet etc.
Is {yourPets} coughing or having other respiratory signs?*
If yes, describe further...Coughing more while sleeping versus when more active/ excited? How does it sound? Is the cough productive? Heavy breathing or excessive panting? Tiring out quicker? Changes with any medications?
Does {yourPets} have sneezing or nasal discharge?*
If yes, describe further....what does the discharge look like (bloody, mucus etc). Left, right or both nostrils? Frequency of sneezing? After sleeping? More outside etc?
How is {yourPets}'s activity level and behavior?*
Please describe if needed.

You are almost done!!

Current Medications *

	Name of Medication	Dose (e.g. mg, units etc.)	Route (e.g. oral, topical etc)	Frequency (how many times per day)
1
2
3
4
5
6
7
8

Do you feel that any of these medications have helped {yourPets}'s signs? Are there any side effects and are they impacting {yourPets}'s or your quality of life? Any difficulties administering (liquids versus tablets?)?
You and your veterinarian have requested this recheck exam. If there are any other records from other veterinarians including previous veterinarians, second opinions, specialty or emergency visits, notes you have taken at home please upload them below or have them e-mailed directly to me (kim@hammer.vet). The more information I have, the better evaluation I can provide.
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Internal Medicine Questionnaire

Clinical Signs at Home

You are almost done!!