FNUS history form

FNUS history form

FNUS history form

FNUS Questionnaire

Form for FNUS client to fill out prior to appointments

*If you are able to, please bring in a free catch urine sample. Please keep refrigerated after collecting**

Client & Patient Information

Doctor you are seeing:
Max. file size: 80 MB.
Is this your pets first visit with Friendship Nephrology-Urology Specialists?
Have they been seen by Internal Medicine or Nephrology-Urology at another veterinary hospital?
Please list all veterinary clinics your pet sees for primary care and/or specialty care. (Click the + icon to add an additional line.)

Patient History - Diet

Please list all food, treats, snacks and other foods your pet is currently eating, including brands and amounts (Click the + icon to add an additional line.):
Brand
Formula
Flavor
Amount
Frequency
 
Example: Hills K/D chicken dry ½ cup twice daily
If your pet has an E-tube are you cleaning the site daily?

Medications

Please list all medications your pet is receiving including dose, strength, form, and frequency (Click the + icon to add an additional line.):
Name
Dose/Strength
Frequency
 
(Example: Gabapentin 100mg 1 capsule twice daily)
Is your pet taking any supplements such as vitamins, glucosamine, fatty acids, nutraceuticals, or herbal treatments?
Name
Dose/Strength
Frequency
 
(Example: Denamarin small dog 1 chew daily)
Are you having any difficulty administering medications to your pet?
What type of medication is easiest to administer to your pet?

Visit Information

How is your pet's appetite?
How would you describe your pet's water intake?

Friendship provides state of the art, comprehensive services for our clients and patients. But, more than that, we provide a caring team who understands the unique human-animal bond. View Our Services