Internal Medicine Questionnaire






SYMPTOMS (Elaborate and include duration as needed)


Normal   Decreased   Increased


Normal   Decreased   Increased


Normal   Decreased   Increased



Normal   Abnormal


   Yes   No


   Yes   No


   Yes   No


   Yes   No


Yes   No


Normal   Decreased   Increased





Yes   No



Yes    No     
Yes    No     
Yes    No     
Yes    No     

PRIOR MEDICAL HISTORY


Yes    No



Yes    No

CATS


Yes    No    Unsure



Yes    No    Unsure



Indoor Only   Indoor/Outdoor    Outdoor Only

MEDICATIONS

Heartworm preventative   
Flea/tick preventative   
Vitamins/other supplements   


Yes    No


DIET



Yes    No


MISCELLANEOUS