Language
English (US)
Medical History: Oncology Recheck
10436 173rd Street, Surrey, BC, V4N 5H3 Phone: 604-514-8383 | FAX: 604-427-2494 | bbvsh.com | info@bbvsh.com | This form can be found again at bbvsh.com/registration
Contact Information
Your name
*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Your pet's name
*
Phone number where you can be reached at the time of consultation
(XXX) XXX-XXXX
Approximate time of pick-up (if you are dropping off)?
e.g. 4pm
Is there anything you would like to discuss with the oncologist today? Please note the oncologist will speak to you prior to treatment if there are any abnormalities on bloodwork or physical exam.
*
Yes, prior to treatment
Yes, at time of discharge
No
Since your last visit...
Is your pet having difficulty breathing?
*
Yes
No
Has your pet’s appetite changed ?
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Yes
No
How would you describe this change in appetite?
Increased appetite and/or thirst
Mildly decreased or needed coaxing to eat
Moderately decreased (3 days or less)
Very decreased (3 days or more)
Not eating, needed medical care
Has your pet had any vomiting?
*
Yes
No
How severe is the vomiting?
Mild: 1-2 episodes, only one day
Moderate: 8 or fewer episodes, two days or less
Significant: many episodes over several days, needed care
Severe: required hospitalization
If medications were given for vomiting, what medications and which days?
Has your pet’s energy level or attitude changed?
*
Yes
No
How would you describe this change?
Improved
Mild lethargy or decreased activity
Lethargic for 3 or more days
Very lethargic, needed care
Severe lethargy, required hospitalization
Has your pet had diarrhea?
*
Yes
No
How would you describe the diarrhea?
Mild: soft stools, no increased frequency
Mild: soft stools with increased frequency or urgency
Moderate: 3-5 episodes, needed medications
Significant: many episodes overseveral days, needed care
Severe: required hospitalization
If medications were given for diarrhea, what medications and which days?
Is your pet coughing?
*
Yes
No
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?
Better
Worse
Same
Is your pet sneezing?
*
Yes
No
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?
Better
Worse
Same
Is there nasal discharge?
Yes
No
How would you characterize the discharge?
e.g. clear, green, bloody
Do you think your pet is in pain?
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Yes
No
Where is the pain?
Is your pet drinking normally?
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Yes
No
Are they drinking more or less?
More
Less
Is your pet urinating normally?
*
Yes
No
Are they urinating more or less?
More
Less
Is there blood in the urine?
Is your pet eating normally?
*
Yes
No
Are they eating more, less or not at all?
More
Less
Not at all
How long have they not been eating?
Has labwork or any other test been performed elsewhere since your last visit to Oncology?
*
Yes
No
Please list here:
Please list any medications your pet is taking (including non-prescription and supplements). Include name, strength(mg), how often, for how long. Please list individually even if prescribed by BBVSH.
*
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months' or N/A
Do you need refills of any medications?
*
Yes
No
Which ones?
OPTIONAL:
HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us.
e.g. I searched Google for X; My vet recommends you for oncology treatment, etc
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