Neurology Consultation Questionnaire Neurology Consultation Questionnaire This form is also available as a fillable PDF. Download Owner's Name:* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Pet's Name:* When was he or she last normal? What was the first sign that you noted? Has your pet had any known exposure to bats? Yes No Has your pet ever traveled to Vancouver Island or outside BC? Yes No Has your pet had any diarrhea or vomiting in the last month? Yes No Has your pet had any coughing or sneezing in the last month? Yes No Has your pet shown any compulsive circling? Yes No Has your pet shown any compulsive pacing? Yes No Has your pet shown any change in behaviour? Yes No Has your pet shown any change in temperament? Yes No Has your pet had trouble recognizing someone familiar? Yes No Has your pet started urinating in inappropriate places? Yes No Has your pet started defecating in inappropriate places? Yes No Has you pet been staring vacantly at the walls? Yes No Has you pet been pressing his or her head into a corner? Yes No Has your pet been bumping into things as if they could not see? Yes No Has your pet had any seizures? Yes No Has your pet had any collapsing episodes? Yes No Has your pet had any loss of balance? Yes No Is your pet taking any medications at the moment? Yes No Is your pet eating and drinking normally? Yes No Has your pet had any other major illnesses or injuries? Yes No If YES, please specify:How old was your pet when you first acquired him or her? Has your pet recently received aspirin (acetylsalicylic acid)? Yes No If YES, please specify the dose and time received:Do you have any other comments?