Hyperthyroid Cat: New Patient Questionnaire TEST

Hyperthyroid Cat - Client Questionnaire - Test

Please do NOT use this form as a means of communicating time sensitive information about your cat. The information provided in this form is only reviewed for content approximately 24 hours before your scheduled admission appointment.
Thank you for scheduling an appointment to have your cat treated with radioiodine at our facility. In an effort to ensure the optimal treatment experience for both you and your cat, please answer the questions below.
Client/Patient Information:
Client Name*
Prefix First Last
Occasionally cats are associated with multiple client names (spouse, partner, co-owner) at referring veterinary offices. To facilitate the retrieval of all pertinent patient information from referring veterinary offices please provide any additional client names your cat could be listed under. If there is more than one individual, please click the + symbol to the right of the input field.
Additional Client Name
Prefix First Last
Patient Name*
First
Medical History - Thyroid:
When was your cat first diagnosed with hyperthyroidism?*
MM slash DD slash YYYY
Has your cat had surgery for hyperthyroidism?*
- Yes
- No
Has your cat been treated with Hills y/d? If you marked yes, please list the first day administered and the last day administered.*
- Yes
- No
Begin Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Has your cat been treated with methimazole (e.g., Tapazole, Felimazole)? If you mark yes, please list the first day administered and the last day administered.*
- Yes
- No
Begin Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Negative Reaction to Methimazole?*
- Yes
- No
Describe Negative Reaction to Methimazole.
- GI Signs (Vomiting and/or Inappetence)
- Hepatopathy (Jaundice)
- Bone Marrow (Anemia, Leukopenia, Thrombocytopenia)
- Dermatologic (Facial Itching and Scratching)
Response to methimazole.
- Symptoms improved/resolved
- Symptoms persisted/worsened
Medical History - Other:
Please list any previous illnesses. If there is more than one disease, please click the + symbol to the right of the input field.
Disease Date Diagnosed Treatment Performed
Please list any drugs that your cat has received within the past year. If there is more than one drug, please click the + symbol to the right of the input field.
Drug Duration Date Last Administered
Symptoms:
You must select an option from the drop down menu. If this symptom has not occurred please select Does Not Apply.
Aggressive Behavior?*
Decreased Appetite?*
Please select the description that best fits your cats Decreased Appetite.
- Decreased appetite exclusively when taking methimazole that resolved when methimazole discontinued.
- Decreased appetite associated with another condition that resolved following treatment. (Please list this condition in Previous Medical History section above)
- Persistently decreased appetite independent of other known conditions or medications.
Depression?*
Diarrhea?*
Foul Smelling Stool?*
Increased Appetite?*
Increased Urination?*
Increased Water Consumption?*
Nervousness?*
Seeks Cool Areas?*
Tremors?*
Vomiting?*
Weakness?*
Weight Loss?*
Dietary History:
Do you want us to feed your cat wet/canned food?*
We carry a variety of canned foods to feed during your cat's hospitalization for radioiodine therapy. However we are not a pet food store and do not carry every variety of canned cat food. If you want your cat to eat a specific variety of canned cat food please bring a sufficient quantity of that food to last for the duration of your cat's stay with us (4-7 days worth).
While we respect the requests of our clients to limit the foods we offer their cats, we reserve the option to offer a variety of food options to ensure adequate calorie intake during the hospitalization for radioiodine therapy.
Do you want us to feed your cat dry food?*
We carry a variety of dry foods to feed during your cat's hospitalization for radioiodine therapy. However we are not a pet food store and do not carry every variety of dry cat food. If you want your cat to eat a specific variety of dry cat food please bring a sufficient quantity of that food to last for the duration of your cat's stay with us (4-7 days worth).
While we respect the requests of our clients to limit the foods we offer their cats, we reserve the option to offer a variety of food options to ensure adequate calorie intake during the hospitalization for radioiodine therapy.
Does your cat have any dietary preferences or restrictions we should know about?
Additional Information, Comments, Concerns
Acknowledgments
COVID-19 Policy - By checking this box I acknowledge the following policy.*
Due to the current COVID-19 pandemic we are NOT accepting any personal items. This includes but is not limited to bedding, clothing, toys, brushes, etc.
If you intend to provide your own cat food for use during your cat's hospitalization for radioiodine therapy, please only bring the estimated amount your cat will require as we will NOT be able to return unused cat food at discharge.
Acknowledged

Δ

locations

3047 Edinger Ave
Tustin, CA 92780
949-559-7289

2340 S. Sepulveda Blvd
Los Angeles, CA 90064
310-477-4453

connect
with us

Disease	Date Diagnosed	Treatment Performed

Drug	Duration	Date Last Administered

Hyperthyroid Cat: New Patient Questionnaire TEST

Hyperthyroid Cat - Client Questionnaire - Test

Client/Patient Information:

Medical History - Thyroid:

Medical History - Other:

Symptoms:

Dietary History:

Acknowledgments