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Oncology Recheck Form
Please fill out this form prior to your pets upcoming oncology appointment
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Email
*
Your email
Please write your pets name below.
Your answer
Please list the name, phone number, and email for the point of contact for your pets upcoming appointment
*
Your answer
Does anyone in your household have a peanut allergy?
*
Yes
No
Does your pet have any allergies?
*
Your answer
Do you plan to wait for your pet at their upcoming appointment?
*
Yes
No
If you need to leave the hospital, or drop your pet off, when is the best time to reach you by phone? (select all apply)
Morning
Afternoon
Evening
Have you noticed any tumor growth or tumor change since your last visit?
*
Increased in size
Decreased in size
Stable in size
New growth noted
Unsure
Not applicable
Has your pet experienced any of the following since their last visit? Please select all that apply.
*
Vomiting
Diarrhea
Coughing
Sneezing
Difficulty Breathing
None of the above
Required
If your pet experienced any of the above symptoms listed, please provide details below, and if any medical action/treatment was given to help alleviate these symptoms.
Your answer
How would you describe your pets food intake?
*
Normal
Normal, but with coaxing or diet change
Decreased
Anorexic
If there has been any change to your pets food intake, how was it treated and for how long?
Your answer
How would you describe your pets water intake?
*
Normal
Increased
Decreased
How would you describe your pets urination? Please select all that apply.
*
Normal
Increased
Decreased
Straining to urinate
Blood noted in urine
Incontinent (leaking urine)
Required
How would you describe your pets energy level since their last visit?
*
Increased
Normal
Moderately decreased
Severely decreased
Is your pet showing any signs of pain or discomfort?
*
No! :)
Mild, but not interfering with daily activity
Moderate (interfering with daily activity)
Severe pain
Unsure
If your pet is showing any signs of pain, please elaborate below:
Your answer
Will your pet be fed the morning of their appointment or fasted? (Please refer to your previous discharges for instructions on if your pet needs to be fasted for their upcoming appointment)
*
Fed
Fasted
Is your pet on any medications? If so,
please list the medication(s), strength, and frequency they are given
. (Please do not write "meds prescribed")
*
Your answer
Do you need any refills of medications? If so, please list the medications you need to be refilled below.
*
Your answer
If indicated, do we have permission to run additional bloodwork during their appointment?
*
Yes
No (would need to talk to doctor first)
If needed, do we have permission to sedate your pet?
*
Yes
No
In the event of cardiac arrest, how would you like us to proceed? (We do not foresee this occurring, however it is hospital policy to have in your pets file)
*
Resuscitate
Do not resuscitate
How would you describe your pets overall quality of life? (1 being poor, and 10 being excellent)
*
1
2
3
4
5
6
7
8
9
10
Please list any other questions or concerns you would like addressed at your pets upcoming appointment.
Your answer
Thank you for entrusting us with your pets care <3
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