MEDICAL HISTORY: Neurology Initial & Recheck

Medical History: Neuro Initial / 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
During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount. As such, we are required by the College of Veterinarians of British Columbia to take additional precautions in providing care to patients from at-risk or COVID-positive households.
Are you, someone in your household, or someone with close contact with your pet either COVID-positive or experiencing any symptoms of COVID-19 (including sore throat, cough, fever, or difficulty breathing)? *

Yes No
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 today *
(XXX) XXX-XXXX
Your pet's name *
What is the present complaint? *
Reason for visit
When did you first notice signs of this problem? *
Has the condition gotten better or worse since it first started? *
Please describe how.
Have you witnessed any seizure activity? *

Yes No
How long were they lasting? *
When was the last episode? *
Is your pet having trouble walking? *

Yes No
When was the last time s/he was able to walk without assistance? *
When was the last time s/he urinated? *
Do you feel your pet is in pain? *

Yes No
Where do you feel the pain is localized? *
Has your veterinarian performed any diagnostic tests for this condition? *

Yes No
Which tests? *
When were they performed? *
Have any medications been used for this condition in the past? *

Yes No
What medications? *
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months' or N/A
Have you stopped giving any of these medications to your pet? *

Yes No
Why did you stop? *
What medications are currently being given?
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months' or N/A
Do you feel the medications have provided any improvement? *
Please explain.
When did your pet last eat? *
OPTIONAL: HOW DID YOU FIND US?
We'd like to understand the specifics of how you discovered us for neurological treatment for your beloved pet:
e.g. I searched Google for 24 hour 'neuro vet'; My vet recommends you for neuro, I've been here before!
Could this form be better? Share your thoughts with marketing@bbvsh.com
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Medical History: Neuro Initial / Recheck