Patient Consult Questionnaire

Activity Level
Appetite
Thirst
Urination
Bowel Movements
Vomiting/Nausea
Respiratory
Stiffness/Pain
Voice Changes
Temperature Preference
Quality of Life
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
Hidden
Current Medications
Add all your pet's medications. Click the + icon to add a new row.
Medication
Dose
Amount
Frequency
Refill needed?
 
Hidden
Current Supplements
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?)