Neurology Appointment Questionnaire



Neurology Appointment Questionnaire

Pet's Name*:

Your Name*:

Appointment Date*:

Present complaint/Why is your pet here today?

What neurologic symptoms is your pet experiencing?

Pain   Weakness   Balance   Other  

How long has this been happening?

Symptoms began:    Suddenly   Gradually

Was it associated with a specific event or injury?

Has it progressed:    Better   Worse

Have you seen a veterinarian for this current issue?

Have other diagnostics been performed for this issue and when? (X-rays, CT or MRI Scan, Other)

Medications

Have you tried medications for this problem?   Yes   No

Which ones?

Did they help?   Yes   No

Have you administered pet medications before?   Yes   No

If so, do you prefer:   Tablets    Liquids

Are you satisfied with medication pricing?   Yes   No

Do you use coupons?    Yes   No

Drug Name Size or Concentration Dose Times Source Date Started

Other current/past health conditions, concerns, surgeries?

Current diet:

For Cats:   Indoor Only   Outdoor Only   Indoor/Outdoor

Is your pet up to date on vaccines?   Yes   No

Has your pet spent time in other regions out of New Jersey?   Yes   No
If so where?