Neurology - Seizure Appointment Questionnaire -Recheck

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Pet name:

Your name:

Layout

Appointment date:

Appointment Location

Frederick
Richmond

When did seizures first start?

When was the most recent episode?

Any change in description of seizures?

Seizure Frequency
Please indicate any of the following that apply

Typical frequency:

Any recent changes:

Is your pet having other new neurologic symptoms? (pain, weakness, balance, lethargy, behavior change, disorientation, vision loss, etc) If so, please describe.

Have recent drug levels been done, and when?

Has any other lab work been done, and when?

Medications
Please indicate any of the following that apply

Recent dose changes or since last visit? If so, when?

Any ongoing side-effects:

Can you give medications every 8 hours (3 times per day)?

Do you prefer tablets or liquid?

Are you satisfied with medication pricing? Do you use coupons?

Current Medications
Please indicate any of the following that apply

Please indicate the number of your pet's current medications.

Med 1

Med 2

Med 3

Med 4

Med 5

Med 6

Other current/past health conditions, concerns, surgeries:

Any other recent changes/updates since last appointment:

Current diet:

Any known allergies:

For cats: indoor only, indoor/outdoor, outdoor only?

Is your pet up to date on vaccines?

Has your pet spent time in other regions out of state?