New Client Questionnaire - Dogs
Clinic you wish to attend
Murdoch
Vet24
Patient Name
*
Owner's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Please tell us how you found us:
*
Veterinary referral
Online search (Google, etc.)
Social media
Word of mouth
Returning client
Other
Do you consent to us posting images of your pet on social media?
*
Does your pet have a social media account?
What is your pets social media account name?
example@example.com
If your pet is insured, which company do you use?
*
What is your pet's policy number?
*
Name of local vet clinic
What is the main problem?
At what age was the condition first noticed?
Have there ever been any previous dermatitis or ear problems?
Yes
No
Symptoms
Have any of the following been observed?
Sores
Heat
Depression
Scabs
Redness
Ear Infections
Dandruff
Diarrhoea
Increased appetite
Hair Loss
Tiredness
Odour
Weight Loss
Increased Thirst
Hives
Weight Gain
Ear Infections
Which ears are affected?
Left
Right
Both
Is one worse than the other?
Left
Right
Both the same
Approximately how many times has your pet been treated for ear infections?
Have any of the following been observed?
Ear discharge
Head tilt
Head shaking
Haematoma
Scratching the ear
Loss of balance
Rubbing the ear
Eye movement
Other
Do you know of any relatives of this pet that have ear problems?
Yes
No
Does your pet:
Rub at the face
Scratch at the sides
Scoot on bottom
Head shake
Lick the stomach area
Eye discharge
Scratch at ears
Roll on the back
Sneeze
Lick or chew the paws
Bite at the tail area
Wheeze or cough
Other
Other (more info if required)
Do the symptoms vary?
If the dermatitis or ear problems have been present for some time, are the symptoms worse in:
Spring
Summer
Autumn
Winter
Are the symptoms present all year round?
Yes
No
Would there be a time of no symptoms at some stage?
Yes
No
What (if anything) causes a worsening of the symptoms?
What helps?
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Home Details
Do you have any other pets?
Yes
No
Other pets:
Do you know of any relatives of the pet that have skin problems?
Yes
No
Does any human in the house have skin problems?
Yes
No
Please estimate how much time your pet spends:
Indoors
%
Outdoors
%
Does your pet swim?
Yes
No
How often & where?
Where does this pet sleep?
What room?
What type of bedding?
What type of flooring do you have in your house?
Where do you walk your pet and how often?
Bathing
Does bathing:
Help
Worsen
Make no difference
What type of shampoo are you using?
How often do you bath your pet?
Weekly
Monthly
Rarely
Other
Insects & Fleas
When was the last time a flea was seen on this pet?
-
Day
-
Month
Year
Date
When was the last time a flea was seen on your other pets?
-
Day
-
Month
Year
Date
What is the current flea treatment on this pet?
How frequently do you use this flea treatment?
Is flea treatment used on other pets?
Do you see other insects in your environment?
Mosquitoes
Ants
Moths
Cockroaches
Flies
Other
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Medication
Please give the name and dose of medication/s given
Ear Drops
Name / Dose & Date Last Given
Tablets
Name / Dose & Date Last Given
Ointments / Lotions
Name / Dose & Date Last Given
Injections
Name / Dose & Date Last Given
Rinses
Name / Dose & Date Last Given
Is your dog on heartworm treatment?
Yes
No
What type of heartworm treatment is being used?
Diet
What do you normally feed your pet?
Cans
Dry
Meat
Table scraps
What is the brand of food?
Which types of meat do you feed your pet?
Any supplements?
(e.g. vitamins, minerals, fatty acids, glucosamine etc)
What do you give for snacks and treats?
Have you ever fed a special diet?
Yes
No
If yes, what diet?
General Health
Has there been any?
Vomiting
Diarrhoea
Mucous stools
Lethargy
Increased water intake
Increased appetite
Weight gain
Weight loss
Weakness
Does your pet have any other illness, if so please specify what medicines are being prescribed?
What do you think could be the cause of the skin problem?
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