SEIZURE/MOVEMENT DISORDER RECHECK FORM

Click HERE for a printable PDF version of this form.

The Following information is important in evaluating your pet. Please bring this completed form with you to your pet’s appointment, or e-mail prior to: [email protected]. Please contact us at 301.200.8185 with any questions.

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Pet Name *

Owner Name *

First

Last

Email *

Appointment Date / Time

Date

Time

Reason for Recheck: *

• Blood Work
• Refills
• Other/Concerns

If not, we will provide a bland diet while your pet is in hospital.

Reason for Recheck: *

When was the most recent episode: *

Change in description of events?

Typical frequency of events?

Any recent health changes?

Is your pet having other new neurological symptoms? (pain, weakness, balance, behavior change, disorientation, vision loss, etc)

Have recent drug levels or other lab work been performed? *

• Yes
• No

If so when/where:

Current Medications

Please fill out to the best of your ability. We also encourage you to bring your pet’s medications to your appointments.

Dose changes since last visit:

Any side effects?

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

• Yes
• No

Every 12 hours (2 times daily)

• Yes
• No

Do you prefer:

• Tablets
• Liquids

Do you use coupons, Good Rx, etc?

Please indicate the number of medications your pet is taking.

• None
• 1
• 2
• 3
• 4
• 5

Medication 1

Drug Name

Pill Size or Liquid Concentration

Dose/How Many

Frequency

Source

Date Started

Medication 2

Drug Name

Pill Size or Liquid Concentration

Dose/How Many

Frequency

Source

Date Started

Medication 3

Drug Name

Pill Size or Liquid Concentration

Dose/How Many

Frequency

Source

Date Started

Medication 4

Drug Name

Pill Size or Liquid Concentration

Dose/How Many

Frequency

Source

Date Started

Medication 5

Drug Name

Pill Size or Liquid Concentration

Dose/How Many

Frequency

Source

Date Started

Other current / past health conditions, concerns, surgeries?

Current Diet: *

Any known allergies or dietary restrictions?* *

• Yes
• No

If yes, please list

FOR CATS:

• Indoor Only
• Outdoor Only
• Indoor/Outdoors

Is your pet up to date on vaccines, including Rabies? *

• Yes
• No

Has your pet spent time in other regions out of the Mid-Atlantic area within the last 6 months? *

• Yes
• No

If so, where?

Submit