Patient Consult Questionnaire

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Activity Level (OLD)
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Appetite (OLD)
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Thirst (OLD)
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Urination (OLD)
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Bowel Movements (OLD)
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Vomiting/Nausea (OLD)
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Respiratory (OLD)
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Stiffness/Pain (OLD)
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Voice Changes (OLD)
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Temperature Preference (OLD)
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Quality of Life (OLD)
Do you need a Medication Refill?*
Add all your pet's medications and if any refills are needed. The Medication, Dose, Amount, and Frequency.
For your reference: BID: twice a day, SID: once a day, PRN: as needed. Please make sure to write *NEEDS REFILL* next to the medication or supplement you need refilled.
Ex. Prednisone 10 mg 1/2 tablet twice daily - Needs Refill
Do you need a Supplement Refill?*
Add all your pet's medications and if any refills are needed. The Medication, Dose, Amount, and Frequency.
For your reference: BID: twice a day, SID: once a day, PRN: as needed. Please make sure to write *NEEDS REFILL* next to the medication or supplement you need refilled.
Ex. Xiao Chai Yu Tang, 1/2 tsp twice daily - Needs Refill
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Current Medications (OLD)
Add all your pet's medications. Click the + icon to add a new row.
Medication
Dose
Amount
Frequency
Refill needed?
 
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Current Supplements (OLD)
Add all your pet's supplements. Click the + icon to add a new row.
Supplement
Amount
Frequency
Refill needed?
 
Recent Vet Visits
Please list all of your pet's recent visits. Click the + icon to add a new row.
Date of Visit
Name of Practice
Why was your pet there and what did the veterinarian do? (Medications, treatments, tests?)