Home » Pre-Consult Form: Neurology – Seizures

Pre-Consult Form: Neurology – Seizures

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

Seizure or Episodes: Documentation

Please use this section to upload any seizure or episode logs or videos.

Seizure or Episode Log

If you have a log of your pet's seizures or episodes, please upload it here.

Drop files here or

Max. file size: 25 MB.

Seizure or Episode Video

If you have a video of your pet's seizure or 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.

Seizure or Episodes: History & Frequency

When did the seizures or episodes first start (or at what age)?

How often are the seizures or episodes occurring?

Describe their frequency

Does the seizure or episode come in clusters - two or more in 24 hours?

Yes

Does your pet ever experience continuous unconscious seizure activity for 5-10 minutes or longer without recovery (status epilepticus)?

Yes

Has your pet had any recent blood tests or drug levels:

Please check all that apply:

Chemistry Panel

Complete Blood Count

Thyroid/T4

Phenobarbital Level

Potassium Bromide Level

Zonisamide Level

Keppra/Levetiracetam

Other

None

What was the test?

Please tell us the following information for each test:

Use the plus sign (+) to add information for multiple tests:

Test Name:

Test Date:

Veterinary Hospital where test was performed:

Seizure or Episodes: Details

Please review the following to describe to us what a seizure and/or episode 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.

Please describe what a seizure or episode looks like for your pet:

Please tell us what your pet's episode starts with:

Are there any identifiable triggers for your pet's episode?

Yes

If yes, please describe:

Does your pet fall to their side during an episode?

Yes

When your pet falls, are they seated or standing?

Seated

Standing

When your pet falls, do they fall to a particular side?

Left

Right

Varies

Unsure

Is there convulsing during an episode?

Convulsing - paddling of the arms and legs

Yes

Does your pet show stiffness during an episode?

Yes

Does your pet twitch during an episode?

Yes

What part of the body twitches?

On a scale of 1-10 how severe is the twitching?

1 being the least severe, 10 being the most severe

Please enter a number from 1 to 10.

Does your pet drool during an episode?

Yes

Does your pet have loss of bowels or urination during an episode?

Yes

Does your pet have odd eye movements or position during an episode?

Odd eye movements: darting back and forth, or going up and down

Yes

Does your pet have enlarged pupils during an episode?

Yes

Is there a noticeable change in your pet's oxygenation status during an episode?

For example pale gums/conjunctiva, blue/purple look to their tongue

Yes

Are you able to get your pet's attention during an episode?

Yes

Can the episode be stopped by getting their attention?

Yes

How long do these behaviors last?

Is there a period of time after the episode where they are still not themselves (post-ictal period)?

Yes

How long does the post-ictal period last?

What happens during the post-ictal period?

For example are they drowsy, confused, blind, frantic, etc.

How long until your pet seems back to their normal self after the post-ictal period?

Please describe any other details regarding your pet's seizure or episode here:

Medications: Seizures

Please fill out this section for seizure medications only. Non-seizure medications will be asked for later in the questionnaire.

Have any seizure medications (anticonvulsants) been tried?

Yes

Please list the medication and following information:

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

Drug:

Mg per tablets/capsules:

How often:

Tablets/capsules per dose given:

Date started:

Lapses in receiving this medication (yes/no):

Has this dose changed? Please describe:

Is your pet currently on this medication (yes/no)?

Last dose given:

Side effects:

Day to Day Activity

Please use the following section to provide us details on your pet during regular, day-to-day activities, between seizures or episodes.

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.

Is your pet acting like themselves in between seizures or episodes?

Yes

If no, what types of behaviors are you noticing?

For example pacing, wandering, bumping into objects or walls, getting stuck in corners/small spaces, hiding, agitation, or behavior change, etc.

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

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

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 previous pertinent medical history?

For example diabetes, surgeries, hospitalizations, etc.

What do you feed your pet?

Medications: Non-seizure

Please use this section to tell us all of your pet's non-seizure medications and/or supplements.

Please list all non seizure/anticonvulsants 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:

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