Internal Medicine Pre-Consultation Questionnaire IM Pre-Consult Form Thank you for visiting our Internal Medicine Department. To better assist us in diagnosing and treating your pet, please take a moment to complete the questionnaire below regarding medical history PRIOR to your appointment time. This information is very helpful in getting an accurate history of your pet’s condition. If you are unable to complete this form prior to your appointment, we ask that you arrive 30 minutes early to fill it out then. The length of your pet's appointment will vary depending on the type of diagnostics and/or severity of their condition. If you have specific time constraints or scheduling difficulties, please contact our internal medicine liaison directly at 518-783-3198. Do not allow your pet to urinate immediately before your appointment (in case we need to collect a urine sample). Do not feed your pet for 12 hours prior to your appointment (water is ok). *If your pet is diabetic, feed and give insulin as usual. Please list or bring any medications or supplements your pet is currently on, or has recently taken (including medication strength and dosages).Date* Client Name* First Last Pet Name* First Last Email* Referring VeterinarianPlease include additional emergency or veterinary clinics we should contact to get all of your pet’s information for their current problemGeneral HistoryAt what age and where was your pet acquired?*Please include breeder/shelter and locationIs your pet spayed/neutered? If so, please include age:*Is your pet current on vaccines?*YesNoIs your pet currently on flea/tick, or heartworm preventatives?*YesNoIf yes, what is the product?Has your pet traveled outside of the area?*YesNoIf yes, when and where?Is your pet indoor only?*For example: does your pet visit dog parks, go to day care, has been recently groomed, or is boarded? YesNoOther than the pet we are seeing here today, how many other pets do you have and what kind are they?*What brand and type (dry, canned, raw, homemade) of food does your pet eat?*Please include how often your pet eats, how long it's been on this diet, and any/all treats given. Does your pet have known allergies?*YesNoIf yes, please list allergies here:Please list any of the following your pet has been diagnosed with, as well as the approximate date they were diagnosed:*diabetes mellitus, hyperthyroidism, hypothyroidism, Cushing's disease, epilepsy, Addison's disease, inflammatory bowel disease, chronic kidney disease, mitral valve disease Please list all current medications and their dosages and supplements here:* Internal Medicine HistoryWhat prompted you to seek the Internal Medicine Specialty service at UVS and what are your goals for this consultation?*When did the problem first develop? Was the problem sudden or gradual in onset?*Have you noticed any changes in your pet's attitude or activity level?*YesNoIf yes, please describe:Have there been any changes to your pet's appetite and/weight?*YesNoIf yes, please describe:Have you seen an increase or decrease in your pet's drinking habits?*YesNoIf yes, please describe:Has your pet had any coughing?*YesNoIf yes, please select all that apply: The cough has stayed the same The cough has been getting worse The cough is dry/hacking The cough is moist/congested The cough is productive The cough is associated with exercise, activity, and/or excitement My pet has exercise intolerance My pet has a history of fainting/collapsing spells Has your pet had any sneezing or nasal discharge?*YesNoIf yes, please select all that apply: Nasal discharge mucus is green Nasal discharge mucus is clear Nasal discharge is bloody Nasal discharge is watery Nasal discharge is one nostril Nasal discharge is both nostrils My pet is unable to breathe through their nose (open-mouth breathing) Has your pet been vomiting (actively retching), regurgitating ("urping" after eating)? Or seems nauseous (drooling, poor appetite) without vomiting?*YesNoIf yes, please list what your pet vomits, when your pet vomits, and how frequently your pet vomits:For example: My pet has vomited foam, after drinking water, for the past 3 days. Has your pet had any changes in bowel movement?*YesNoIf yes, please check all that apply: The stool is soft The stool is liquid The stool is bloody The stool is mucus The stool is black/tarry The stool is greasy There has been an increase in frequency or amount Has your pet had any changes in urination?*YesNoIf yes, please select all that apply: My pet is urinating large amounts of dilute urine My pet is drinking large amounts of water My pet is urinating more frequently My pet is straining or having difficulties when urinating My pet is urinating in inappropriate places My pet has blood in their urine My pet is having incontinence or dribbling/leaking while walking, lying down or sleeping Based on any previous veterinary treatments (special diets, medications, therapies) for your pet's current problems, have you noticed any improvement in clinical signs at home?*YesNoIf yes, please tell us which treatment or medications you feel helped and list any side effectsPlease include additional comments and concerns here:PhoneThis field is for validation purposes and should be left unchanged.