Oncology Questionnaire



First Name*:

Last Name*:

Email Address*:

NorthStar VETS Location:

Robbinsville     Maple Shade

Patient Name*:

What cancer has your pet been diagnosed with?

What was the first sign that you saw if any?

How long has your pet had these signs? days/weeks/months/years

Has your pet had a biopsy or fine needle aspirate of his/her cancer?    Yes   No

If yes, do you have results with you?    Yes   No     faxed by my regular veterinarian

Has your pet had bloodwork performed in the last month?    Yes   No

If yes, do you have results with you?    Yes   No     faxed by my regular veterinarian

Has your pet had radiographs (xrays) performed in the last month?    Yes   No

If yes, do you have results with you?    Yes   No     emailed by my regular veterinarian

Has your pet had any other tests performed in the last month?    Yes   No

What test(s)?

If yes, do you have results with you?    Yes   No    faxed by my regular veterinarian

Do you have any other pets?    Yes   No

Please put breed and ages of other pets:

Is your pet on flea/tick preventative?    Yes   No

Is your pet on heartworm preventative?    Yes   No

For cats: Has your pet been tested for FeLV/FIV?    Yes   No

If yes, at what age was your pet tested weeks/months/years

Does your pet have any other previously diagnosed medical or surgical
problems unrelated to the cancer?    Yes   No

If yes, please describe:

Please list all medications that your pet is on, doses (if you know), how often and for how long your pet has been on the medication. Please include Drug, Pill size (mg), How often and How long has he/she been on this medication?

Have you noticed any change in the health or behavior of your pet that coincided with the development of the cancer? (e.g. changes in food or water intake, changes in urination or defecation, changes in activity level?    Yes   No

If yes, please list:

Describe the current diet of your pet including brand names and any table foods, treats, biscuits, vitamin supplements, or rawhide chews given?