Neurology – New Seizure Appointment Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Pet Name *Your Name *Your Email *Appointment Date *Appointment Location *FrederickRichmondWhen did seizures first start? *When was the most recent episode? *Do you have videos of seizures? *YesNoHave you seen a veterinarian for this current issue? *YesNoIs your pet having other neurologic symptoms? (pain, weakness, balance, lethargy, behavior change, disorientation, vision loss, etc) Description of Events Please indicate any of the following that applyDuration/lengthFacial twitching (focal) or full body (grand mal)?Awake or non-responsive?Collapse?Paddling legs or still?Vomiting/drooling/foaming at mouth?Vocalizing?Urination or defecation?What occurred prior to event? Abnormal behavior before or after? Duration?OtherFrequency Typical frequency:Any recent changes:Patterns/time of day:Diagnostics Has any labwork been completed? If so, when?Have other diagnostics been done for this issue, and when? (X-rays, CT or MRI scan, other)Medications Can you give medications every 8 hours (3 times per day)? *YesNoHave you given your pet medications before? *YesNoDo you prefer tablets or liquid? *TabletsLiquidAre you satisfied with medication pricing? *YesNoDo you use coupons? *YesNoIf your pet needs medications called into a local human pharmacy, is there a location you would prefer?Current Medications Please indicate the number of your pet's current medications.None123456Medication 1Drug NameSourceSize/ConcentrationDate StartedDoseSide EffectsTimeMedication 2Drug Name SourceSize/ConcentrationDate StartedDoseSide EffectsTimeMedication 3Drug Name SourceSize/ConcentrationDate StartedDoseSide EffectsTimeMedication 4Drug NameSourceSize/ConcentrationDate StartedDoseSide EffectsTimeMedication 5Drug NameSourceSize/ConcentrationDate StartedDoseSide EffectsTimeDose Medication 6Drug Name SourceSize/concentrationDate StartedSide effects TimeOther current/past health conditions, concerns, surgeries:Current diet:Any known allergies:For cats: indoor onlyindoor/outdooroutdoor onlyIs your pet up to date on vaccines? YesNoIs your pet on monthly preventatives?YesNoIf yes, please list:Has your pet spent time in other regions out of state? YesNoIf yes, please provide details:Submit
