Patient Medical Questionaire

Rocky Shores Veterinary Hospital, P.C.

341 Route 25A
Rocky Point, NY 11778

(631)209-2035

www.rockyshoresvet.com

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)

Current Environment: (required)

Indoor only
Limited outside exposure
Mostly outside
Outside only

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
None
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
(Not Applicable)

When did you FIRST notice the problem(s)? [ie "5 days ago"] (If not applicable, type "NA") (required)

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