How do I take a clinical history?

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Introduction

When a client brings his or her pet to your veterinary practice, it might be for a routine check-up or because the animal is sick.

In both cases, you will need to ask a series of questions to the owner in order to assess your patient’s health.

The following pages will teach you ways to obtain information from the patient’s owner in English, so you can offer the best service possible and avoid any misunderstandings.

The words in blue indicate useful general expressions.

The words in dark red indicate useful technical and medical terms.

Click on or tap the red buttons to discover more information.

Asking for information when there are signs of disease

When an animal is showing signs of disease, the vet should ask a series of questions before starting the physical examination.

“OK, Mrs. Petersen. Before starting with the physical examination, I’d like to ask you some questions to help me find what is wrong with Bean.”

In this part of the consultation, the vet must prompt the owner to mention any signs of disease he or she might have observed, as pet owners may otherwise be too vague when describing their pet’s problem.

You can start the question by “Have you noticed any… ?” and complete it with any signs the pet owner may have observed: vomiting, diarrhoea, coughing, sneezing, seizures, itching, hair loss, abnormal nasal/ear/vaginal discharge, changes in the animal’s appetite and changes in the animal’s drinking/sleeping/playing habits, etc.

Note: Diarrhoea is the British spelling of the word. Americans write diarrhea. Medical terms in British English have retained the original spelling of their Greek roots, while Americans have simplified these roots so their spelling is in accordance with how they are pronounced.

  • Have you noticed any…?
  • What was …. like?
  • How long has …. been …?
  • Can you describe …?

To assess the severity of the signs observed, it is necessary to ask the owner for precise information. Let’s see some example questions, depending on the possible origin of the problem:

Gastrointestinal system

  • How long has Blacky been eating less?
  • When did the vomiting first start?
  • What colour are her stools? What are her stools like?
  • Were there any dark spots in her stools?
  • What is Blacky fed? What do you usually feed her?

Urinary system

  • Have you noticed any changes in the amount of water Leah is drinking?
  • Has she been urinating more or less than usual in the past few days?

Skin

  • Has your cat been scratching a lot recently?
  • Have you observed any abnormal hair loss?
  • Do you regularly bathe your dog?

Respiratory system

  • Has he had any difficulty breathing?
  • Does Dexter get short of breath when he runs or plays?
  • Has he become intolerant to exercise?
  • Has Dexter had any cough at all? How long has he been coughing for?
  • Has he been panting even at rest?