Rocky Shores Veterinary Hospital, P.C.

341 Route 25A
Rocky Point, NY 11778

(631)209-2035

rockyshoresvet.com

Patient Medical Questionaire

The completion of this form is REQUIRED for check-in.
Date (required) :
Name of registered client: (required)
First Name (required)
Last Name (required)
Patient Name (required)

List any current medications, supplements, and previous or ongoing medical conditions, or "NONE": (required)

Parasite Prevention
Which product do you use to prevent INTERNAL parasite infections? (required)
Interceptor
Sentinel
Heartgard
Trifexis
AdvantageMulti
Revolution
None
Other--Indicate below:




Which product do you use to prevent EXTERNAL parasite infestation? (required)
Advantage
K9 Advantix
AdvantageMulti
Revolution
Frontline
Other--Indicate below:




Current diet and feeding schedule: (required)

Treats, Chews,Toys: (If none, indicate "NONE") (required)

Primary Reason for today's visit: (required)
Wellness visit/vaccinations
Refill/Renew prescription medication(s)
I am concerned about the following:
Attitude/Behavior (required)
Normal
Lethargic/Depressed
Shaking/Trembling
Other--Describe below:


Appetite (required)
Normal
Increased
Decreased


Drinking (required)
Normal
Increased
Decreased


Urination (required)
Normal
Increased
Decreased


Gastrointestinal (required)
Normal
Vomiting
Diarrhea
Constipated
Scooting
Other--Describe below:


Respiratory (required)
Normal
Coughing
Sneezing
Abnormal breathing
Discharge from nose
Other--Describe below:


Skin/eyes/ears/mouth (required)
Normal
Itchy/scratching
Check ears
Check skin
Check teeth
Bad breath
Discharge from eyes
Other--Describe below:


Musculoskeletal (required)
Normal
Trouble walking, limping
Trouble getting up
Abnormal gait
Other--Describe below and/or indicate affected limb(s):


Duration and Occurrence
Check all that apply: (required)
First time problem
Problem has happened in the past
Problem is intermittent
Problem has worsened
Problem exists, but is stable
When did you FIRST notice the problem(s)? [ie "5 days ago"] (required)


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