Ilderton Pet Hospital

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EMERGENCY

Gastrointestinal Concern Pre-Visit Questionnaire

To ensure we provide the best possible care for your beloved companion, we kindly ask you to fill out the following questionnaire prior to your upcoming appointment. Your responses will help us gather important information about your pet’s health history and current condition.

Pre-Visit Gastrointestinal Concerns Questionnaire

Client FIrst Name(Required)

Client Last Name(Required)

Patient Name(Required)

Current diet (including brand and type of food) and treats or table food.

Any recent changes in diet or treats?(Required)

Yes

No

If yes, please describe.

Is your pet experiencing any of the following symptoms?(Required)

Vomiting

Diarrhea

Constipation

Blood or Mucus in the Stool

Decreased Appetite

Increased Appetite

Weight Loss

Lethargy

Abdominal Pain or Discomfort

Increased Gas or Bloating

Other

Please check all that apply.

If you chose "Other", please specify.

How long has your pet been experiencing these symptoms?(Required)

Have you tried any treatments at home?(Required)

Has your pet ever had gastrointestinal issues in the past?(Required)

Yes

No

If yes, please describe.

Have you noticed any triggers or patterns associated with your pet's gastrointestinal issues?(Required)

Yes

No

Unsure

If yes, please describe.

Is your pet prone to eating inappropriate items inside, scavenging items, or ingesting prey outside?(Required)

Yes

No

If yes, can you think of anything they could have ingested?

Has your pet had any recent exposure to toxins, foreign objects, or unusual foods?(Required)

Yes

No

If yes, please describe.

Is your pet currently on any medication or supplements?(Required)

Yes

No

If yes, please list the name(s), dose(s), and frequency in which they are administered.

Is your pet drinking water and urinating normally?(Required)

Yes

No

If no, please describe.

Please provide additional information or details you believe may be helpful for our veterinary team to know.

Please attach any photos you may have that are related to the presenting concern.

Accepted file types: jpg, jpeg, png, gif.

For example, a photo of the stool, vomit, or anus. *This is especially helpful if a telemedicine appointment has been booked.

Thank you for taking the time to complete this questionnaire. Your cooperation is greatly appreciated and will assist us in providing the best possible care for your pet. If you have any urgent concerns or questions before your appointment, please don’t hesitate to contact us.

Warm regards,

IPH

Mailing Address

Box 462, 125 King St.
Ilderton, ON N0M2A0

Phone: (519) 666-2288

Office Hours

Monday	8:30am – 5:00pm
Tuesday	8:30am – 5:00pm
Wednesday	8:30am – 5:00pm
Thursday	8:30am – 5:00pm
Friday	8:30am – 5:00pm
Saturday	8:30am – 12:00pm
Sunday	Closed

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