MEDICAL HISTORY: Oncology Recheck

Medical History: Oncology Recheck

#202 – 20434 64 Avenue, Langley, BC Phone: 604-514-8383 | FAX: 604-427-2494 www.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 ? *

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? *

Yes No
Where is the pain?
Is your pet drinking normally? *

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 during your time of emergency.
e.g. I searched Google for 24 hour emergency vet; My vet recommends you for emergencies, etc
Feedback on this form? Send your thoughts to marketing@bbvsh.com
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Medical History: Oncology Recheck

Contact Information

Since your last visit...