MEDICAL HISTORY: Oncology Initial

Medical History: Oncology Initial

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Contact Information
Your name*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Phone number where you can be reached at the time of consultation
(XXX) XXX-XXXX
Your pet's name*
What is your primary concern today?*
Reason for visit
When did you first notice the problem?*
How has it progressed? Has it gotten significantly worse?*
Which tests have been performed?*

BiopsyCytologyNeither
Does your pet have any other major illnesses of which we should be aware? *
Is your pet currently experiencing any of the following symptoms?
Difficulty breathing?*

YesNo
Collapse?*

YesNo
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures?*

YesNo
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
Coughing?*

YesNo
When did it start?
How often does it occur?
Has the coughing gotten better, worse, the same?

BetterWorseSame
Is your pet sneezing?*

YesNo
When did it start?
How often does it occur?
Has the sneezing gotten better, worse, the same?

BetterWorseSame
Is there nasal discharge?

YesNo
How would you characterize the discharge?
e.g. clear, green, bloody
Vomiting?*

YesNo
When did it start?
How often does it occur?
Has the vomiting gotten better, worse, the same?

BetterWorseSame
Is the your pet actively vomiting (heaving) or is it more like an urp?
Diarrhea?*

YesNo
When did it start?
How often does it occur?
Has the diarrhea gotten better, worse, the same?

BetterWorseSame
Is there urgency to go?
Is there any blood in the diarrhea?
Is the diarrhea black like tar?
Lameness?*

YesNo
Which leg?
When did it start?
Has it gotten worse?
Do you think your pet is in pain?*

YesNo
Where is the pain?
Is your pet drinking normally?*

YesNo
Are they drinking more or less?

MoreLess
Is your pet urinating normally?*

YesNo
Are they urinating more or less?

MoreLess
Is there blood in the urine?
Is your pet eating normally?*

YesNo
Are they eating more, less or not at all?

MoreLessNot at all
How long have they not been eating?
What is your pet's normal diet?*
Does your pet have any food allergies?*
To what?
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
Please list any medications to which your pet has had an allergy or has had a bad reaction?*
Or enter 'NA'
Please list any allergies:*
Or enter 'NA'
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for oncology treatment for your beloved pet:
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 Initial

Contact Information

Is your pet currently experiencing any of the following symptoms?