619-462-6820 contact@ranchosancarlospet.com

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ACTH StimulationHistory Form

Make the most of your next appointment by saving time! Before your appointment, fill out your ACTH Stimulation History form from any device at any time.

acth

ACTH Stimulation History Form

Name *

First

Last

Pet's Name *

What SIZE Trilostaine (Vetoryl) does your dog receive?

5mg
10mg
30mg
60mg
120mg
none

How many TIMES per day?

Once (every 24 hours)
Twice (every 12 hours)
Other

What TIME did your pet their most recent dose?

Was the Trilostaine given with food?

Yes
No

When your dog was diagnosed with Cushing’s, how much was he/she drinking compared to 1 year prior to diagnosis?

A lot less
A little less
About the same
A little more
A lot more
Not sure

How much is your dog drinking now, compared to when he/she first started the Vetoryl/trilostaine?

A lot less
A little less
About the same
A little more
A lot more
Not sure

Has your dog had any urinary accidents/leakage within the past month?

No
Yes, but less
Yes, about the same as before
Yes, more than before
Not sure

How active is your dog compared to when he/she started taking Vetoryl/trilostaine?

A lot less
A little less
About the same
A little more
A lot more
Not sure
Other

How is your dog's appetite changed since the beginning of treatment?

A lot less
A little less
About the same
A little more
A lot more
Not sure

How is your dog's panting changed since the beginning of treatment?

A lot less
A little less
About the same
A little more
A lot more
Not sure

How is your dog's hair coat changed since the beginning of treatment?

A lot less hair
A little less hair
About the same
A little more hair
A lot more hair
Not sure
Other

Overall, how do you think your dog is doing in terms of the clinical signs of Cushing's?

A lot worse
A little worse
About the same
A little better
A lot better
Not sure
Other

Have you given any steroids (prednisone, dexamethasone, etc)?

Yes
No

If yes, how much? when? and what happened?

Has your dog had any

Vomiting
Diarrhea
Trembling
Signs of illness
Other

If yes, how much? when? and what happened?

Best Phone Number to reach you at today

Email *

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Visit the Rancho San Carlos Pet Clinic

We look forward to seeing you and your pet. You may request an appointment by using our convenient online system!

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Address

7850 Golfcrest Dr, San Diego, CA 92119

v

Contact

P: 619-462-6820
F: 619-462-2064
E: contact@ranchosancarlospet.com

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Hours

Mon-Fri: 7:00 am – 6:00 pm
Sat: 8:00 am – 5:00 pm
Sun: Closed

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