Home » Pre Consult Form: Neurology – Cranial Neuropathy

Pre-Consult Form: Neurology – Cranial Neuropathy

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

Cranial Neuropathy: Details

Please review the following to describe to us what cranial neuropathy looks like for your pet.

**IMPORTANT**

Please note it is important for consistency and localization of potential problem areas to indicate your pet's left and right sides. Left and right are defined as if you were standing directly beside them or put in their position, not when looking at them head-on.

Does your pet seem visual/are they able to see?

Yes

Do they bump into objects at home?

Yes

What other behaviors might suggest your pet cannot see well, or at all:

Have you noticed any abnormal pupil size?

Yes

Is one pupil bigger or smaller than the other?

Yes

If yes, which eye?

Does your pet have any abnormal reaction to light or brightness?

Yes

Do you notice either eye ball pointing in an odd direction ("lazy eye")?

Yes

If yes, which eye and which direction?

(up, down, left, or right)

Is your pet unable to blink one or both eyes?

Yes

If yes, which eye?

Have you noticed any drooping of the face, lip, ear, or eyelid?

Yes

If yes, which side?

Has your pet had any unusual crusting of the nose?

Yes

If yes, which side, or both?

Does your pet have any protrusion of the 3rd eyelid?

Third eyelid: the small pink or black membrane in the inner corner of the eyes.

Yes

If yes, which eye:

Does your pet have any muscle atrophy on the top of the head? Does it appear sunken in, or do you see more of the bone structure on the head?

Yes

Does your pet itch, scratch, or rub their face excessively?

Yes

If yes, which side?

Are they making contact when they scratch?

Yes

Does your pet have difficult opening or closing their jaw all the pet?

Yes

Have you noticed them drooling excessively or see thick saliva in their water bowl?

Yes

Does your pet have difficulty getting or keeping food in their mouth?

Yes

Does your pet have any difficulty chewing or swallowing food or water?

Yes

Do you hear or see any coughing, choking, gagging, retching, or regurgitation?

Yes

Has your pet had any changes to their voice or bark?

Yes

If yes, please describe:

Have you noticed any abnormal tongue movements?

Yes

Is your pet's head tilted to one direction or another?

Yes

If yes, tilted to which direction?

Right head tilt = left ear is higher Left head tilt = right ear is higher

Have you seen any jerking motions of the eyeballs or eyelids?

Yes

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

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

Yes

Is your pet up to date on vaccinations? Including Rabies

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, fell off furniture/bed, etc.)

Yes

If yes, please tell us what and when:

Does your pet have any previous pertinent medical history?

For example diabetes, surgeries, hospitalizations, etc.

What do you feed your pet?

Medications and Supplements:

Please list all current medications and supplements:

Click the plus sign (+) to add another medication.

Drug:

Strength (mg per tablets/capsules):

Dose (how many tablets/capsules per dose given):

Frequency (how often):

First Started:

Last Dose Given:

Side Effects:

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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