Seizure ReCheck Appointment Questionnaire



Seizure Re-Check Appointment Questionnaire

Pet's Name*:

Your Name*:

Appointment Date*:

When did the seizures first start?

When was the most recent episode?

Change in description of seizures?

Typical frequency of seizures?

Any recent changes?

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

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

Medications

Dose changes since last visit?

Any on-going 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?

Any known allergies?

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?