Pre-visit Survey For Medical Issues Of Dogs

Pre-visit Survey For Medical Issues Of Dogs

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Urinary Problems

Dog’s Name *

Your Name *

First

Last

Email *

Phone Number *

Please tell us about your dog’s diet. *

Please tell us about any treats, dental chews, and human food your dog receives. *

Please tell us about any other prescription, OTC medications, &/or supplements your pet is taking, including current dose and frequency.

The following are relevant to my pet? (Mark all that apply) *

• Change in environment
• Change in housemates
• Change in schedule
• None
• Other

Please explain the changes in the here:

Are they having accidents in the house? *

• Yes
• No

Are there changes in the frequency of urination in your pet? *

• Yes
• No
• Not sure

Can your pet urinate normally? *

• Yes
• No
• Not sure

When your pet urinates, is it a steady stream? *

• Yes
• No
• Not sure

Is there constant dribbling? *

• Yes
• No
• Not sure

Is your pet only incontinent when lying down or asleep? *

• Yes
• No
• Not sure

If it occurs only during sleep, is it a large volume?

Is it worse on:

• a full bladder
• empty bladder
• no difference

Is the dribbling worse right after your pet urinates?

• Yes
• No
• Not sure

I’ve noticed the following changes in my pet’s urine (Mark all that apply): *

• Odor
• Appearance
• Amount
• None
• Other

Please explain the changes

Has their thirst increased or decreased? *

• Increased
• Decreased
• Stayed the same

Are they having normal bowel movements? Both in frequency and appearance? *

• Yes
• No

How are your pet’s activity levels? *

• Higher than Normal
• Lower than Normal
• The same

How long have these changes been going on or when did you first notice a problem?

If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.

Vomiting/Diarrhea

Is your pet vomiting? *

• Yes
• No

How often is your pet vomiting? *

Are they having normal bowel movements? Both in frequency and appearance? *

• Yes
• No

How often is your pet having diarrhea? *

What is the consistency? *

How are your pet’s activity levels? *

• Higher than Normal
• Lower than Normal
• The Same

Is your pet still trying to eat? *

• Yes
• No

Did your pet receive (Mark all that apply):

• Any Human foods
• Get new/abnormal treats
• Take any medications not prescribed for them
• Chew on household items
• Get into the trash
• Get into anything in the yard

Are any other pets in the household showing similar symptoms? *

• Yes
• No

Has your pet been to the dog park, boarding, or been exposed to pets that are not in the household? *

• Yes
• No

How long have these changes been going on or when did you first notice a problem?

If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.

Skin Rashes & Itchiness

Which flea & tick prevention is your dog receiving? *

• Bravecto
• Nexgard
• Credelio
• None
• Other

Is urinate all

When was your dog’s last dose given? *

Does your pet seem itchy? *

• Yes
• No

Is your pet shaking his/her head? *

• Yes
• No

When was the problem first noted? *

Where on the body was the problem first noted? *

Are any other pets at home experiencing similar problems? *

• Yes
• No

Have you been treating with anything at home, including shampoos, ointments, oral medications or other OTC medications?

If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.

Lumps & Skin Growths

If you have noticed multiple lumps, please answer the questions about all the lumps.

When did you first notice the lump?

Has it grown?

Does the pet bother it?

Has it changed in texture or appearance?

If you have any questions or concerns you would like to discuss with the doctor during your visit, please list them here.

Other Medical Problem

Please describe concerns you that would like to discuss with the doctor during your visit. *

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