Home » Pre-Consult Form: Neurology – Weakness/Difficulty Walking

Pre-Consult Form: Neurology – Weakness/Difficulty Walking

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

Weakness/Difficulty Walking: Details

Please review the following to describe to us what weakness or difficulty walking 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.

Which leg(s) are affected?

For example - all four, just hind limbs, one side of the body, one limb, etc.

How long has this been going on for?

Was the onset of symptoms sudden or have they progressed over time?

Sudden

Progressed over time

If progressive, over what period of time?

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 the floor?

Yes

Do any of their limbs criss-cross when they walk?

Yes

If yes, which limbs?

Have you seen your pet stand or walk on the tops of their feet with their paws bent under?

Also known as knuckled or knuckling

Yes

Is your pet able to jump?

Yes

Does your pet have trouble jumping onto beds, furniture, or into the car?

Yes

Is your pet able to climb stairs?

Yes

If no, do they have trouble:

Going up

Going Down

Both

Does your pet's back appear hunched or arched when they stand?

Yes

Does your pet carry their head low?

Yes

Do they have limited range of motion to their neck?

Yes

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

Yes

Does your pet seem painful?

Yes

If yes, please describe what behaviors suggest this:

If yes, where does the pain seem to be coming from?

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

Yes

If yes, is it:

Dribbling of urine

Dropping of stool

Both

Has your pet been straining to urinate or defecate, or had difficulty passing urine or stool?

Yes

How does your pet hold their tail?

Down

Between the legs

To the side

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

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, how has it changed?

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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