BHVH - Canine Patient History Questionnaire

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Please use this form to send us information we need to give your dog the best possible medical care.

When you arrive, please ring the doorbell to let us know you are here and someone will come and help you with your four legged friend! While you wait outside, the doctor will perform their exam and call you to go over their findings.

Email *

What is your dog's name?

What is your first and last name?

What phone number should the doctor use to speak with you?

What is the date and time of your appointment? *

YYYY

Time

Please briefly describe the primary reason for your pet's visit. The next section will ask for further details.

Do you have any reason to suspect that your animal has been in contact with anyone who was exposed to COVID-19 (Coronavirus)? *

Yes

Unsure

How is your dog feeling?

Doing great! Everything is back to normal or is better than it has been!

Doing well. My dog is feeling the same as he or she always does.

I'm concerned. My dog is displaying some odd behavior.

I'm worried. My dog is not acting like him or her self at all.

My dog is displaying highly worrisome behavior. Please call the hospital immediately at (718) 624-1200. If we are closed or no one answers please call Blue Pearl or VERG immediately.

Other:

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Have you noticed an increase of any of the following? Please select all that apply.

Coughing. My dog is coughing more than usual.

Sneezing. My dog is sneezing more than usual.

Vomiting. My dog is vomiting more than usual.

Diarrhea. My dog is having diarrhea for longer than is normal.

Soft stool. My dog is having soft stool for longer than is normal.

None of the above

Other:

How is your dog's appetite?

It has increased. My dog's appetite is higher than normal.

It's the same. No change.

It has decreased. My dog's appetite is lower than normal.

Other:

Clear selection

Are there any changes to your dog's drinking habits?

My dog is drinking more than normal.

My dog is drinking the same as he or she always does.

My dog is drinking less than normal.

Other:

Clear selection

Are there any changes in your dog's urination?

My dog is urinating more than usual.

My dog is urinating the same amount as he or she always has.

My dog is urinating less than normal.

Other:

Clear selection

Is your dog displaying any odd or unusual behaviors like scooting, or licking of the paws and genitals? (if yes, please specify)

Is your dog scratching his or her ears or shaking his or her head more than usual?

Yes

Other:

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What kind of food are you feeding your dog?

Wet. I feed my dog wet food.

Dry. I feed my dog dry food.

I feed a combination of wet and dry

Please specify food manufacturer and type.

How frequently do you feed your dog?

Once per day.

Twice per day.

Three times per day.

I put down food and my dog eats when he or she is hungry.

Other:

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How much food do you feed your dog per feeding?

Is your dog groomed or boarded at a facility?

Yes

Other:

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Are there any other pets in your home? (if yes, please specify)

Do you travel with your dog outside of Brooklyn or New York City? (if yes, please specify)

Does your dog take heartworm or parasite prevention?

Yes. My dog takes both heartworm and flea & tick preventatives.

My dog ONLY takes flea & tick preventatives.

My dog ONLY takes heartworm preventatives.

My dog does not take either heartworm or flea & tick preventatives.

Other:

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Do you need more flea and tick preventative or heartworm preventative for your dog? If so, what products do you use and how many months would you like?

Is your dog currently taking any medication? (if yes, please specify medication name, dose, and how frequently you administer it)

Do you need refills of any medictions? If so, which ones?

Are you able to get your dog to take pills?

Yes

I've never tried

Clear selection

Does your dog have a history of vaccination reactions?

Yes

I don't know

Clear selection

Are there any other questions or concerns that you'd like the doctor to know?

Submit

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