Seizure Appointment Questionnaire



Seizure Appointment Questionnaire

Pet's Name*:

Your Name*:

Appointment Date*:

When did the seizures first start?

When was the most recent episode?

Do you have videos of seizures? Yes   No

Description of Seizures (check all applicable or explain)

Duration / length:

Facial twitching only (focal):

Full body movement (grand mal):

Awake:

Non-responsive:

Collapse:

Paddling legs:

Still legs:

Vomiting/drooling/foaming at the mouth:

Vocalizing:

Urination or defecation:

Stimulating/trigger events:

Abnormal behavior before or after, (duration):

Other:

Frequency of Pet's Seizures

Typical frequency:

Any recent changes?

Patterns/time of day:

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

Have you seen a veterinarian for this current issue?

Have recent drug levels or other lab work been performed and if so, when?

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

Medications

Recent dose changes

Any witnessed side effects?

Can you give medications every 8 hours(3 times per day)   Yes   No

Every 12 hours(2 times per day)   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?

Any other recent changes/updates since last appointment?

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?