Pre-Consult Form: Internal Medicine

Internal Medicine Pre-Consult Form

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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 Information

Client Name*

First Last

Pet Name*

First Last

We’ve implemented emailing clients with their pet’s routine lab results. Client communication is a top priority, and we want to be sure our clients are comfortable with this communication method. Please note, a member of our team will always call with important changes regarding your pet’s health.

Are you okay with receiving your pet’s lab results via email?*

Yes, I am okay with emailed lab results

No, please have a team member call me with lab results

Please confirm your email*

Referring Veterinarian

Please list all veterinary hospitals in which your pet has been previously evaluated. Use the plus sign to add another hospital.

Consultation Information

Please tell us what prompted you to schedule an appointment with the Internal Medicine service?

Please tell us your goals from this consultation?

When did this problem first develop?

Was the problem sudden or gradual?

General History

Species

Canine

Feline

Breed

Approximate Age or Date of Birth

Sex

Male

Female

Spay/Neutered

Yes

Unsure

How long have you had your pet?

Where was your pet acquired from?*

Current Clinical Signs

Is your pet's energy level normal?

Yes

Is your pet currently coughing?

Yes

If yes, how often?

Is your pet currently sneezing or having discharge from their nose?

Yes

If yes, how often?

Is your pet currently vomiting?

Yes

If yes, how often?

Is your pet currently having diarrhea or soft stool?

Yes

If yes, how often?

Is your pet's appetite normal?

Yes

If no, for how long?

Is your pet drinking more water than normal?

Yes

If yes, how often?

Is your pet currently urinating more often than normal?

Yes

If yes, how often?

Does your pet have any issues with mobility, limping, or lameness?

Yes

If yes, please describe:

Medical History

Does your pet have a history of respiratory disease?

Yes

If yes, please describe:

Does your pet have a history of urinary disease?

Yes

If yes, please describe:

Does your pet have a history reproductive disease?

Yes

If yes, please describe:

Does your pet have a history of gastrointestinal disease?

Yes

If yes, please describe:

Does your pet have a history of skin disease?

Yes

If yes, please describe:

Does your pet have a history of orthopedic disease?

Yes

If yes, please describe:

Does your pet have a history of neurological disease?

Yes

If yes, please describe:

Does your pet have a history of cardiac disease?

Yes

If yes, please describe:

Does your pet have a history of ocular disease?

Yes

If yes, please describe:

Does your pet have a history of endocrine disease?

For example: Thyroid disease, Diabetes, Cushing's disease, Addison's disease, etc.

Yes

If yes, please describe:

Has your pet had any surgeries in the past?

Yes

If yes, please describe:

Medications:

Please list all current medications and supplements your pet is taking.

If you do not have this information at this time, please bring it with you to the appointment.

Drug

Dose

Frequency

Please list any previously used medications to treat your pet's current conditions:

Have you noticed any improvements in your pet's symptoms with any current or previously used medications?

Preventatives:

Does your pet receive flea/tick prevention?

Yes

If yes, please indicate which product?

If yes, please indicate how often:

Does your pet receive heartworm prevention?

Yes

If yes, please indicate which product?

If yes, please indicate how often:

Diet History

Please describe your pet's current diet:

Brand, canned, dry, raw, or homemade:

How many cans/cups per day does your pet eat?

Does your pet have any treats?

Yes

If yes, please describe:

Do you feed your pet human food/table scraps?

Yes

If yes, please describe:

Please list any diets your pet has tried in the past:

Use the plus sign to add more diets.

Have you noticed any improvements in your pet's symptoms with any current or previously used diets?

Please include additional comments and concerns here:

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Pre-Consult Form: Internal Medicine

Internal Medicine Pre-Consult Form

Client Information

Consultation Information

General History

Current Clinical Signs

Other General Questions:

Medical History

Medications:

Preventatives:

Diet History