PET INFORMATION
Patient (required) Species: DogCat
CLIENT INFORMATION PLEASE ANSWER THE QUESTIONS ON THIS PAGE AS COMPLETELY AS POSSIBLE. OFTEN SIGNIFICANT CLUES TO YOUR PET’S NEUROLOGICAL PROBLEMS MAY BE GLEANED FROM THE HISTORY. IF YOU ARE UNSURE PLEASE INDICATE THAT FACT.
Your Name (required)
Your Email (required)
Best Phone Number (required)
Date Form Filled Out (required)
Why are you filling out this form? For example “had a seizure” or “could not awaken pet”. Be as specific as possible as to what happened & when.
For example “I was getting his dinner ready & he got really excited, he started acting strange, shivering, trembling, then fell over and his legs were paddling and he was drooling & he peed. It lasted about 20 seconds and then he lay there and after about a minute he got up but seemed groggy for about another 10 minutes” is much more helpful than “Had a fit” (required)
Is your pet up to date on it’s Rabies vacine? YesNoUnsure
Does your pet go outside? YesNo
If so, are they ever unsupervised? YesNo
Do they sometimes run free? YesNoUnsure
Has your pet been exposed to any rat, mouse, mole or gopher bait? YesNoUnsure
Has your pet been exposed to any mice or rats? YesNoUnsure
Is your pet much of a hunter? YesNoUnsure
Has the lawn been treated in the last 24-48 hours? If so, would your pet have walked through the grass? YesNoUnsure
Have your neighbor’s treated their lawn recently? YesNoUnsure
Have you or a neighbor treated the garden with a slug or snail poison? YesNoUnsure
Have you used a flea or tick product(s) recently? YesNoUnsure
Please list name of product & when you used it:
Have you used any household or garden insecticides recently? YesNoUnsure
Was your residence built prior to the 50s? YesNoUnsure
Has your pet chewed linoleum or rug padding recently? YesNoUnsure
Has your pet had access to antifreeze recently? YesNoUnsure
Are there any batteries missing that you know of? YesNoUnsure
Would your pet ingest a foreign (non-food) object? YesNoUnsure
Is there any chance your pet could have eaten a golf ball? YesNoUnsure
Is there any chance your pet could have eaten lead fishing sinkers? Lead pellets or shot? YesNoUnsure
Children’s toys made in China? YesNoUnsure
Is there any chance your pet could have eaten window putty? YesNoUnsure
Window caulking or roofing material? YesNoUnsure
