ACTH Stimulation Testing & Vetoryl/trilostaine Monitoring Appointment History Form

ACTH Stimulation Testing & Vetoryl/trilostaine Monitoring Appointment History Form

For the monitoring during treatment of Cushing's Disease
Your Name

First Name Last Name
Pet's Name
What SIZE Trilostaine (Vetoryl) does your dog receive?

5 mg 10 mg 30 mg 60 mg 120 mg None
How many TIMES per day?

Once (every 24 hours) Twice (every 12 hours)
What TIME did your pet their most recent dose?
Was the Trilostaine given with food?

Yes No
When your dog was diagnosed with Cushing’s, how much was he/she drinking compared to 1 year prior to diagnosis?

A lot less A little less About the same A little more A lot more Not sure
How much is your dog drinking now, compared to when he/she first started the Vetoryl/trilostaine?

A lot less A little less About the same A little more A lot more Not sure
Has your dog had any urinary accidents/leakage within the past month?

No Yes, but less Yes, about the same as before Yes, more than before Not sure
How active is your dog compared to when he/she started taking Vetoryl/trilostaine?

A lot less A little less About the same A little more A lot more Not sure
How is your dog's appetite changed since the beginning of treatment?

A lot less A little less About the same A little more A lot more Not sure
How is your dog's panting changed since the beginning of treatment?

A lot less A little less About the same A little more A lot more Not sure
How is your dog's hair coat changed since the beginning of treatment?

A lot less hair A little less hair About the same A little more hair A lot more hair Not sure
Overall, how do you think your dog is doing in terms of the clinical signs of Cushing's?

A lot worse A little worse About the same A little better A lot better Not sure
Have you given any steroids (prednisone, dexamethasone, etc)?

Yes No
If yes, how much? when? and what happened?
Has your dog had any:

Vomiting Trembling Diarrhea Signs of illness
If yes, how much? when? and what happened?
Best Phone Number to reach you at today:

Area Code Phone Number
Email
example@example.com
Should be Empty:

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