Home » Pre-Consult Form: Neurology – Episodes

Pre-Consult Form: Neurology – Episodes

Please complete the following form at least 48 hours before your scheduled appointment. Thank you.

Contact Information

Date

MM slash DD slash YYYY

Client Name

First Last

Pet's Name

First Last

Episodes: Documentation

Please use this section to upload any episode videos of your pet.

Episode Video

If 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

Max. file size: 25 MB.

Episodes: Description and Details

In 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

Is there any muscle twitching or spasms during your pet's episode?

Yes

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

If yes, please describe the trigger:

Behavior and Medical History

What 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

Has your pet experienced any vomiting?

Yes

Has your pet experienced any diarrhea?

Yes

Has there been any blood in your pet's stool?

Yes

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

If yes, please describe:

Has there been any changes to your pet's weight?

Yes

Is your pet up to date on vaccinations?

Yes

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

Please tell us what type and how many:

Does your pet have any travel history?

For example down south, out west, etc.

Yes

Has your pet gotten into anything recently?

For example medications, chemicals, garbage, animals/carcasses, etc.

Yes

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

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:

Have any other medications been tried for this problem?

Yes

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

If yes, please tell us the tests:

Do you have copies of these tests?

Yes

Have copies of these tests been sent to our office before your visit?

Yes

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