8650 W. Tropicana Avenue, Ste. B-107, Las Vegas, NV 89147

Reopening Soon!
North Rainbow Veterinary Emergency Hospital
4445 North Rainbow Blvd, Craig & Rainbow, Las Vegas, NV 89108

Phone: 702-871-1152

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Prescription Refills

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Neurology – New Patient Questionnaire

Neurology – New Patient Questionnaire

Thank you for taking the time to completely fill out the following questionnaire. The more we know about your pet, the better we can provide the best medical care.
Client Name
Pet's Name
Date
MM slash DD slash YYYY
Who is your primary Veterinarian?
How long have you owned your pet?
Where was your pet obtained? (Breeder, Humane Society, etc.)
What is your primary concern about your pet today?
When did you first notice the problem?
Is the problem? (please select)
- Getting better
- Staying the same
- Getting worse
Has there been a recent change in your pet’s behavior or activity level?
- Yes
- No
if Yes, explain:
Has your pet been experiencing any abnormal episodes (Seizures, painful episodes, etc.)
- Yes
- No
if Yes, explain:
Do you feel your pet is in pain?
- Yes
- No
if Yes, explain:
Has there been any changes in your pet’s walking ability?
- Yes
- No
if Yes, explain:
Has your pet been treated for any major medical problems?
- Yes
- No
if Yes, explain:
Has any blood work been done within the past 3 months?
- Yes
- No
if Yes..... When?
Has any x-rays been taken within the past 3 months?
- Yes
- No
if Yes..... When?
Current medications, herbs, vitamins, or supplements your pet is currently receiving at home:
Name
Strength (mg)
# of tab/caplets
Frequency given
Last Given
Refill?
- Yes
- No
Please check here to add more
- Add more
Name
Strength (mg)
# of tab/caplets
Frequency given
Last Given
Refill?
- Yes
- No
Please check here to add more
- Add More
Name
Strength (mg)
# of tab/caplets
Frequency given
Last Given
Refill?
- Yes
- No
Please check here to add more
- Add More
Name
Strength (mg)
# of tab/caplets
Frequency given
Last Given
Refill?
- Yes
- No
Please made additional comments/concerns on the remainder of the page:
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Las Vegas Veterinary Specialty Center | 8650 W. Tropicana Avenue, Ste. B-107 | Las Vegas, NV 89147
Phone: 702-871-1152, Fax: 702-262-7000
Copyright 2015 Las Vegas Veterinary Specialty Center - Las Vegas Veterinarians.

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