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River Road - Patient Consult Questionnaire
In order to best utilize our time together and address all of your concerns, please fill out the following questionnaire before your pet's appointment.
11
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1
Patient Consult Questionnaire
*
This field is required.
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- **Pet's Name**
- **Your Full Name**
- **Appointment Date**
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2
- **Your phone number**
- **Alternate phone number**
- **Your email address**
- **Reason for appointment?**
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3
*How is your pet's...*
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Please Select
Normal
Abnormal
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- **Appetite?**
**If abnormal, please elaborate:**
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- **Water intake?**
**If abnormal, please elaborate.
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- **Urination?**
**If abnormal, please elaborate.**
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- **Bowel Movements?**
**If abnormal, please elaborate.**
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4
*
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Yes
No
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No
- **Has your pet been vomiting?**
**If yes, please provide detail.**
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Yes
No
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No
- **Any recent change in activity/energy levels?**
**If yes, please provide detail.**
- **Has your pet been scratching? If yes, please provide detail.**
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5
- **What heartworm prevention is your pet currently taking?**
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**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
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6
- **What flea and tick prevention is your pet currently taking?**
*
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**Product name**
**How often is it used?**
**When was the last treatment?**
**Do you need a refill?**
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7
- **What food(s) does your pet eat, and how much/how often are they fed? Any treats?**
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8
- **What medications and/or supplements is your pet taking? Do you need refills?**
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Please provide prescription strengths and quantity/frequency given if possible.
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9
*
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- **Is your pet indoor, outdoor, or both?**
- **To what other animals is your pet exposed?**
- **Are there any behavioral issues you would like to discuss?**
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10
- **Are there any other general health concerns you would like to discuss?**
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11
- **Do you need advice on stress-free transport or medication?**
Yes
No
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