Home » Pre-Consult Form: Neurology – Vestibular

Pre-Consult Form: Neurology – Vestibular

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

Vestibular: Details

Please review the following to describe to us what vestibular issues look 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.

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

Sudden

Slowly Progress

If progressive, over what time frame?

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

Better

Worse

Stayed the same

Does your pet seem off balance?

Yes

Do they seem uncoordinated?

Yes

Do they have a wobbly gait, or walking as if they were "drunk"?

Yes

When your pet stands/walks, do they list, lean, or veer to one direction?

Yes

If yes, which direction?

If your pet is unable to stand/walk, are they falling or rolling to one direction?

Yes

N/A

If yes, which direction?

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 odd eye movements?

Eyes darting back and forth or up and down

Yes

If so, is it consistent, or does it come and go?

Have you seen any odd eye positioning, or one eye drifting downwards or outwards? (strabismus or a "lazy eye")

Yes

Have you noticed enlarged or small pupil(s)?

Yes

If yes, which pupil?

Is your pet experiencing any nausea, drooling, vomiting, or loss of appetite due to these symptoms?

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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