Prescription Check

First Name *

Surname *

First Line of Address *

Postal Code

Email Address *

Phone Number *

Pet's Name *

My Pet is a: *CatDogOther

Please tell us your pet's species *

Age *

Breed *

Gender *

Select *

Other

Health Monitoring

Please complete the following to help us monitor your pet’s condition and treatment. This will help us understand how your pet is progressing, and we will discuss this in more detail during your appointment.

Appetite

Have you noticed any changes in your pet's appetite? *IncreasedDecreasedNo changeOther

Please describe *

Thirst

Have you noticed any changes in drinking habits? *Drinking moreDrinking lessNo changeOther

Please describe

Urination

Please describe

Defeacation

Please describe

Respiration

Please describe

Energy Levels

How are your pet's energy levels? *NormalLethargicMore active than usualOther

Please describe

Behaviour

Have you noticed any behavioural changes? *

Exercise

How is your pet managing physical activity? *

Medication

Please describe

Mobility

Have you noticed any changes in movement or mobility? *

Comfort and Quality of Life

Any Other Concerns

Please tell us about any other signs, symptoms, or concerns.

Your Pets Demeanour

0 - Never

1 - Occasionally

2 - Often

3 - All the time

My pet is depressed and quiet *

-

My pet has no energy *

-

My pet doesn’t want to interact with other people/pets *

-

My pet is reluctant to play with me *

-

My pet seems disorientated/confused *

-

Physical Impact

I struggle with my pet's weight *

-

My pet's hair/coat is in a poor condition *

-

My pet’s skin appears to be uncomfortable (e.g. dry/tight) *

-

My pet appears to be in a poor physical condition (e.g. muscle loss/pot bellied) *

-

My pet struggles to walk very far *

-

Owner Impact

I worry about the future health of my pet *

-

Mine and my pet’s daily routine is disrupted *

-

I feel I am struggling to manage my pet’s health *

-

I feel the bond between me and my pet is lacking *

-

I feel my pet’s appearance attracts negative comments *

-

Thank you.

Thank you for taking the time to fill out this questionnaire. The information you give us, along with the physical prescription check, will help us ensure your pet is on the correct medication and at the correct dosage.

Please complete the following questionnaire before your appointment to help us monitor your pet’s condition and treatment. This form is suitable for pets with conditions such as Cushing’s, Addison’s, Diabetes, Renal Disease, Hyperthyroidism, or Hypothyroidism.