Medical History: Oncology Initial
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.
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?
*
Biopsy
Cytology
Neither
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?
*
Yes
No
Collapse?
*
Yes
No
How many collapse episodes have occurred?
After the episode, does your animal return to normal immediately?
Seizures?
*
Yes
No
How many seizures?
When was the last seizure?
Is your pet on any anti-seizure medications? Which one(s)?
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
Vomiting?
*
Yes
No
When did it start?
How often does it occur?
Has the vomiting gotten better, worse, the same?
Better
Worse
Same
Is the your pet actively vomiting (heaving) or is it more like an urp?
Diarrhea?
*
Yes
No
When did it start?
How often does it occur?
Has the diarrhea gotten better, worse, the same?
Better
Worse
Same
Is there urgency to go?
Is there any blood in the diarrhea?
Is the diarrhea black like tar?
Lameness?
*
Yes
No
Which leg?
When did it start?
Has it gotten worse?
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?
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
Save for later
Submit
Feedback on this form?
Send your thoughts to marketing@bbvsh.com
Should be Empty: