Home » Pre-Consult Form: Neurology – Spinal Pain

Pre-Consult Form: Neurology – Spinal Pain

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

Contact Information

Date

Month

Day

Year

Client Name

First Last

Pet's Name

First Last

Spinal Pain: Details

Please review the following to describe to us what spinal pain 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 painful?

Yes

What kind of behaviors suggest this?

Where does the pain seem to be coming from?

How long has it been going on for?

Was the onset of symptoms sudden, or did they slowly progress over time?

Sudden

Slowly progress

Since you first noticed symptoms, has it gotten better, worse, or stayed the same?

Better

Worse

Stayed the same

Does your pet drag or scuff any of their paws?

Yes

If yes, which paw and how often?

Do you hear their nails scrape on floors?

Yes

Does any of your pet's limbs criss-cross when they walk?

Yes

If yes, which limb?

Have you seen them stand/walk on any of the tops of their feet with paws bent under?

Aka knuckled/knuckling

Yes

Which leg(s) seem to be the most affected?

Is your pet able to jump?

Yes

If yes, do they have trouble jumping?

Yes

Is your pet able to climb stairs?

Yes

If yes, do they have trouble going up or down?

Down

Both

Does your pet appear hunched or arched when they stand?

Yes

Does your pet carry their head low?

Yes

Do they limit the amount of range that they move their neck/head around?

Yes

Do you see any muscle spasms/twitching around their neck or along their back?

Yes

Is your pet able to eat and drink out of their food and water bowls normally?

Yes

Do they struggle to reach the bowls?

Yes

Does your pet have accidents in the house they seem to be unaware of? Any incontinence?

Yes

Does your pet have dribbling of urine?

Yes

Does your pet have dropping of stools?

Yes

Is your pet able to wag their tail?

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 your pet had any choking, gagging, retching, or regurgitation?

Yes

If yes, which and when?

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? 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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