Oncology Recheck Questionnaire/Consent Oncology Recheck Questionnaire/Consent Please fill out this form prior to your oncology appointment. Name * Name First First Last Last Email * Phone (cell) * Dr. Rassnick will call you after your pet's exam and/or bloodwork are complete. What is the best number to reach you in the next hour? Pet Information Pet Name * Have you noted any signs of tumor growth since your last appointment? NoYes Describe your pet's activity level since your last appointment * NormalIncreasedMildly DecreasedModerately DecreasedSeverely Decreased Describe your pet's food intake since your last appointment * NormalIncreasedAte normal amount but needed coaxing or diet changeDecreased If your pet had a decreased appetite, how was it treated and for how many days? Did your pet have any vomiting since last appointment? * NoYesUnsure If your pet was vomiting, how many times? 1-2 times3-5 times6 or more times If your pet vomited more than once, were the vomit events: Less than or equal to 15 minutes apartMore than 15 minutes apart How soon after the last appointment did vomiting begin? * Hours1 day2-3 days4 or more days How many days did vomiting last? * 1 day2-4 days5 or more days How was your pet treated for vomiting and for how many days? Describe your pet's stools since last appointment * Normal/formedSoftDiarrhea If your pet had diarrhea, how many times per day did it occur? OnceTwice3-6 times per day7 or more per day If your pet had diarrhea, how soon after the last appointment did it begin? Hours1 day2-3 days4 or more days If your pet had diarrhea, how was your pet treated for it and for how many days? Describe your pet's water consumption * NormalIncreasedDecreased Describe your pet's urination frequency * UnchangedIncreased up to 2x normalIncreased more than 2x normalDecreased Was your pet leaking urine since the last appointment? * NoYesUnsure Was your pet straining to urinate? * NoYesUnsure Have you noticed blood in your pet's urine? * NoYesUnsure Have you noticed your pet to cough or have difficulty breathing since the last appointment? * NoYesUnsure If yes, please characterize Is your pet showing signs of being in pain since the last appointment? * NoMild pain, not interfering with daily activityModerate pain, interfering with daily activitySevere pain, severely affecting daily activityDisabling painUnsure Are there any other clinical signs or symptoms you are concerned about? * Has your pet been fed today? * NoYes If your pet has been fed, at what time? List the medications your pet is receiving, including the dosage (milligrams and amount given per day) Do you need refills of medications and, if so, which one(s)? The information I have provided is true and accurate. I understand that I will be given an opportunity to discuss my pet's progress and condition with the oncology service. I will discuss all of my questions and concerns with the oncology service during this visit so that I can make the informed decision to continue chemotherapy for my pet. I understand that I retain the right to discontinue therapy at any time at my discretion. * I agree and understand Captcha If you are human, leave this field blank. Submit
