Internal Medicine Questionnaire Recheck

Cushing's Quality of Life Questionnaire
Dear Pet Parent:

The Cushing's Quality of Life Questionnaire is designed to fine tune your pet's Cushing's therapy. Not only do we care about how your pet is doing, but we also care about positive and negative trends over the course of therapy. This form should be filled out every time we recheck your pet for Cushing's so we can take into account the whole picture before makign any dose adjustments or recommendations. The numbers after each answer are used by me to tally a total score and look at these trends over time. Thank you in advance for sharing this information and helping me help you and your pet!

Sincerely,

Dr. Hammer

This questionnaire has been adapted from the following reference: Macfarlane L, Parkin T, Ramsey I. Pre-trilostane and three-hour post-trilostane cortisol to monitor trilostane therapy in dogs. Vet Rec. 2016 Dec 10;179(23):597. doi: 10.1136/vr.103744.
Your pet's name*
Pet parent's name*

First NameLast Name

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Are you using brand name Vetoryl or compounded trilostane?*

VetorylCompounded trilostane
If using compounded trilostane, where are you getting it from?*
What time of day are you giving trilostane? *
If the time of administration varies or it was given at a different time the day of the cortisol testing, please note the different times.
What dose in milligrams of trilostane are you giving?*
If you are giving different sizes, just write the total dose (e.g. 10mg capsule plus 5mg capsule =15mg).

Other Current Medications (with the exception of trilostane which was answered above). If you have already filled this out in conjunction with the recheck questionnaire, please feel free to skip or just write same.

	Name of Medication	Dose (e.g. mg, units etc.)	Route (e.g. oral, topical etc)	Frequency (how many times per day)
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Please share any additional information or general updates as to how {yourPets} is doing including any concerns that you would like to share?
You and your veterinarian have requested this recheck exam. If there are any other records from other veterinarians including previous veterinarians, second opinions, specialty or emergency visits, notes you have taken at home please upload them below or have them e-mailed directly to me (kim@hammer.vet). The more information I have, the better evaluation I can provide. Cushing's syndrome can be challenging to manage in some dogs and very straightforward in others. Reviewing this information helps me identify when things are and are not going well and help you give {yourPets} the very best outcome.
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Cushing's Quality of Life Questionnaire

Clinical Signs at Home

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