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Out of hours 01603 867330
Taverham Hospital 01603 867330
Longwater Lane 01603 747344
Bure Valley 01263 733949

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Medicine Referral Patient Questionnaire (Canine)

Your Details

Your Pet's Details

Gender:
Please complete the following questionnaire prior to your medicine referral appointment and bring the completed questionnaire with you to your appointment. 
 

Background Information

Does your pet live:
Does your pet get walked in the following areas:
Please tick all that apply
Does your pet swim?:
Is your pet prone to scavenging on walks or to chewing/swallowing objects, e.g. socks/toys?:
Has your pet ever travelled outside of the UK, or been imported from a country outside of the UK?:
Has your pet received a vaccination within the last 12 months? :
Do you give your pet any preventative parasite treatments (for worms, fleas and ticks)?:
Is your pet neutered?:
Has your pet ever been raw fed?:
Is your pet receiving any dietary supplements?:
Does your pet have any known or suspected dietary allergies?:
Is there any suspected access to toxins?:

Pre-existing Conditions

In addition to the primary reason for referral today, does your pet have any pre-existing conditions?:
Are any of these conditions ongoing?:
Is your pet currently receiving any medications?:
Has your pet ever experienced any side effects in response to any medications?:

Current General Health

Would you describe your pet’s appetite as:
Has any unexpected weight loss been noted?:
Would you describe your pet’s drinking as:
Is your pet’s urination:
Is your pet straining to pass urine?:
Does your pet’s urine look:
Are your pet’s bowel movements:
Would you describe your pet’s faeces as:
Using the Stool Chart below, please indicate the grade of faeces (Score 1 – 7):
Does your pet ever strain to pass faeces?:
Is there any blood noted in your pet’s faeces, or does your pet ever pass very dark (black) faeces?:
Does your pet vomit:
If vomiting is seen, does this tend to occur:
If vomiting is present, is there ever any blood noted in the vomit?:
Would you describe your pet’s activity level as:
Does your pet appear to be in pain?:
Does your pet’s breathing at rest appear:
Does your pet appear out of breath during, or following exercise?:
Is coughing noted:
Is the frequency of coughing:
Would you describe the cough as:
Does your pet ever cough up any phlegm or other material when coughing?:
Does the cough appear to be associated with/triggered by any of the following:
Have you noticed any change in tone of your pet’s bark?:
Is sneezing noted:
Is there any abnormal nasal discharge?:
If present, is the nasal discharge:

Relating to your pet’s current problem (reason for referral today)

To date, has your pet received any treatment for this current condition?:
Is your pet still currently receiving any treatment/medications for this condition?:
Security Question: