Pre-Consult Form: Neurology – Weakness/Difficulty Walking Please complete the following form at least 48 hours before your scheduled appointment. Thank you. Contact InformationDate Month Day Year Client Name First Last Pet's Name First Last Email Weakness/Difficulty Walking: DetailsPlease 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 No If yes, which paw and how often? Do you hear their nails scrape on the floor? Yes No Do any of their limbs criss-cross when they walk? Yes No 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 No Is your pet able to jump? Yes No Does your pet have trouble jumping onto beds, furniture, or into the car? Yes No Is your pet able to climb stairs? Yes No If no, do they have trouble: Going up Going Down Both Does your pet's back appear hunched or arched when they stand? Yes No Does your pet carry their head low? Yes No Do they have limited range of motion to their neck? Yes No Is your pet able to eat and drink out of their food and water bowls normally? Yes No Does your pet seem painful? Yes No 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 No 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 No How does your pet hold their tail? Down Between the legs To the side Is your pet able to wag their tail? Yes No Behavior and Medical HistoryWhat 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 No Has your pet experienced any vomiting? Yes No Has your pet experienced any diarrhea? Yes No Has there been any blood in your pet's stool? Yes No 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 No If yes, how has it changed? Has there been any changes to your pet's weight? Yes No Is your pet up to date on vaccinations? Including Rabies Yes No 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 No Please tell us what type and how many: Does your pet have any travel history?For example down south, out west, etc. Yes No Has your pet gotten into anything recently?For example medications, chemicals, garbage, animals/carcasses, etc. Yes No 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 No 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: Add RemoveHave any other medications been tried for this problem? Yes No 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 No If yes, please tell us the tests: Do you have copies of these tests? Yes No Have copies of these tests been sent to our office before your visit? Yes No