Seizure / Movement Disorder New Consult Form (Form #2) Seizure/Movement Disorder New Consult Form (Form #2) The following information is important in evaluating your pet. Please complete this form before your appointment. Please contact us at (301) 444-6500 with any questions. Pet's Name * Pet's Date of Birth * Appointment Date * Owner Name * Owner Name First First Last Last Phone * Email * When did episodes first start? * When was the most recent event? * Typical frequency, or changes over time Patterns/time of day Do you have videos of the episodes? * Yes No Description of Seizures (check all applicable or explain) Duration/LengthDuration/Length Facial Twitching only (focal)Facial Twitching only (focal) Full body movement (grand mal)Full body movement (grand mal) Remains conscious/awakeRemains conscious/awake Unconscious/non-responsiveUnconscious/non-responsive CollapseCollapse Padding/thrashing legsPadding/thrashing legs Still/cramping legsStill/cramping legs Trembling/shivering legsTrembling/shivering legs Vomiting/drooling/foaming at the mouthVomiting/drooling/foaming at the mouth VocalizingVocalizing Urination/DefecationUrination/Defecation Stimulation/trigger eventStimulation/trigger event Abnormal behavior before or afterAbnormal behavior before or after OtherOther Is your pet having other neurological symptoms? (pain, weakness, balance, behavior change, disorientation, vision loss, etc) Have you seen a veterinarian for this current issue? If so when/where? Have recent drug levels or other lab work been performed? If so when/where? Have other diagnostics been performed for this issue? (X-rays, blood work, CT or MRI Scan, Other) If so when/where? If you are human, leave this field blank. Next
