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VetTech: Taking a Good History in the Exam Room

by Lori Hehn - Mar 30, 2018 6:09:12 AM
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There are many pieces of a pet’s history that may be valuable in helping to obtain a correct diagnosis or treatment for the pet.

The following list of questions should be asked at each visit. Some hospitals will have a questionnaire sheet for the owner to fill out when they arrive which can help to make for a more efficient visit.

As a veterinary technician, you are one of the first points of contact and play a key role in taking a good history for the doctor.

VetTechs

  • Is your pet having any coughing, sneezing, vomiting, or diarrhea?
  • Is your pet drinking normal amounts of water or drinking more than usual?
  • Is your pet eating normally? More or less?
  • Does your pet travel or has your pet traveled recently? Where/when?
  • When was your pet last vaccinated? (Get vaccine records from new clients)
  • Is your pet taking any medications? Which medications and dosages? (Be sure to ask about parasite preventatives and over the counter medications which owners often forget to
    mention.)
  • Is your pet indoor/outdoor/both?
  • Are there other pets in the home?
  • How is his/her activity/energy level? Has that changed?
  • Has the pet had any major surgery or medical history? (for new clients)
  • What diet are you feeding and how much? Treats?
  • Ask questions specific to the presenting complaint. (Example: they are presenting to check a new lump; ask when did they first notice the lump, has it changed in size or appearance and how so? Does it seem to bother the pet (does the pet scratch or lick at it), etc.)
  • Ask the client what their main concerns are so that they all may be addressed by the doctor.

 After taking a good history, you are ready to present the case to the veterinarian! 

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About Lori Hehn

Lori Hehn is a practicing veterinarian and a contributor and content manager with XPrep Learning Solutions. She has a drive for continual learning and enjoys interacting with veterinary and vet tech students. She also writes veterinary learning books for children.

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