A Brief Recap of the Client Interview
Important information to gather when initiating the session (this is usually available to the veterinarian prior to greeting the client):
- Date of examination (important for medical record entry)
- Signalment (client and patient identification)
- Presenting complaint (the reason the client is presenting the animal)
Continue gathering information by developing the presenting complaint (history of the present illness)
- Onset, duration, frequency
- Location, severity
- Progression or improvement of the problem
- Factors that increase or decrease clinical signs
- Have medications been used (product, dosage, duration, response)
Perform a body systems review to identify localizing and non-localizing clinical signs
- Attitude, activity, behavior
- Appetite, weight change
- Water intake and urination
- Presence of vomiting, diarrhea
- Presence of coughing, sneezing
- Additional questions might include (depending on the individual patient):
- Masses, changes in haircoat
- Discharge from eyes, nose, vulva, prepuce
- Change in gait or lameness
Perform a general overview to identify risk factors created by the animal/other animals, the people associated with the animal, and the animal’s environment.
- Environment (where obtained, current environment, lifestyle, travel, other pets)
- Vaccination (what was given and when)
- Diet
- Parasite control (internal parasites, fleas or external parasites, heartworm)
- Past medical history (previous diseases, trauma, surgery)
- Current medications (prescription, over-the-counter, alternative)
- Family history if possible, to assess genetic predispositions
- Current health status
