Pre-Consult Form: Neurology – Episodes Please complete the following form at least 48 hours before your scheduled appointment. Thank you. Contact InformationDate Month Day Year Client Name First Last Pet's Name First Last Email Episodes: DocumentationPlease use this section to upload any episode videos of your pet. Episode VideoIf you have a video of your pet's episode, please upload it here. If your video is too large to upload, please email the video to info@uvsonline.com. Subject: Attention Neurology: Pet's First Name Last Name - Seizure Video Drop files here or Select files Max. file size: 256 MB. Episodes: Description and DetailsIn your own words, please describe what an episode looks like for your pet: During your pet's episodes, do you notice any of the following?Please check all that apply Stiffness Rigidity Paddling Flailing Drooling Foaming Urinating Vocalizing During your pet's episodes, do you notice any of the following?Please check all that apply Balance loss Incoordination Listing Leaning Swaying Rolling Falling to one side Head tilt Abnormal eye movements During your pet's episodes, is there any:Please check all that apply Coughing Difficulty breathing Shortness of breath Exercise intolerance Stops breathing Tongue turns blue Pale gums Loss of consciouness Is there any yipping, yelping, or crying out in pain during your pet's episode? Yes No Is there any muscle twitching or spasms during your pet's episode? Yes No When do the episodes occur? During rest During sleep During activity, exercise, or stress Do all of your pet's episodes look the same or do they change in appearance? Look the same Change in apperance Is there an identifiable trigger to your pet's episodes? Yes No If yes, please describe the trigger: Behavior and Medical HistoryWhat is your pet's energy or activity levels?Please describe your pet's activity levels - are they playful, interactive, etc. Is this normal, increased or decreased recently. How is your pet's appetite? Normal Decreased Increased How is your pet's thirst? Normal Decreased Increased How is your pet's urination? Normal Decreased Increased Has there been any coughing or sneezing out of the ordinary? Yes No Has your pet experienced any vomiting? Yes No Has your pet experienced any diarrhea? Yes No Has there been any blood in your pet's stool? Yes No Please tell us if your pet has experienced any of the following:Check all that apply: Choking Gagging Retching Regurgitation None If yes, please describe and include how often. Has there been any changes to your pet's voice or bark? Yes No If yes, please describe: Has there been any changes to your pet's weight? Yes No Is your pet up to date on vaccinations? Yes No What products do you use for flea/tick prevention?If you're unsure of the brand, please tell us if it is topical or applied to the skin, an oral tablet, or a collar. What products do you use for heartworm prevention?If you're unsure of the brand, please tell us if it is topical or applied to the skin, an oral tablet, or injectable. Do you have other pets in the house? Yes No Please tell us what type and how many: Does your pet have any travel history?For example down south, out west, etc. Yes No Has your pet gotten into anything recently?For example medications, chemicals, garbage, animals/carcasses, etc. Yes No If yes, please tell us what and when: Does your pet have any history of trauma?For example hit by a car, falling down stairs, choking, etc.) Yes No If yes, please tell us what and when: Does your pet have any other previous pertinent medical history?For example diabetes, surgeries, hospitalizations, etc. What food do you feed your pet? Medications and Supplements:Please list all current medications and supplements:Click the plus sign (+) to add another medication. Drug:Mg per tablets/capsules:How often:Column tablets/capsules per dose given:Date started:Last dose given: Add RemoveHave any other medications been tried for this problem? Yes No If yes, please tell us what drugs and the timeframe used: Have any tests been done at your primary care veterinarian to investigate these clinical signs?For example, blood work, x-rays, etc. Yes No If yes, please tell us the tests: Do you have copies of these tests? Yes No Have copies of these tests been sent to our office before your visit? Yes No