I-131 Referral Form

Cat Specialist: I-131 Referral Form

Owner’s Name:
Cat’s Age: Cat’s Weight:

Current clinical signs (circle):

Cat’s Name:_________________________ Cat’s Sex ______ Initial HT4 Diagnosis Date_____________

Weight Loss
Decreased appetite/anorexia Vomiting

Increased Appetite Dyspnea
Diarrhea

Other:_________________________________________________________________________ ______________________________________________________________

Medical conditions in addition to hyperthyroidism (circle):
Renal disease Cardiac disease Dental disease Liver disease

Other: _________________________________________________________________________ _________________________________________________________________________

Do we have your permission to discuss with this client and provide for this cat, additional diagnostics and/or treatments which may be helpful in managing the cat’s ancillary disease(s)? ________

Behavior (circle): Aggressive

Physical Exam findings:
Body condition: Emaciated

Normal Very Shy

Thin Normal Overweight cm L: cm

Thyroid gland palpation: R:
Heart: Murmur: grade
Lungs: Normal Tachypnea

HR Gallop rhythm Open Mouth Breathing

Arrhythmia

Laboratory values: PLEASE PROVIDE COPIES Date of initial hyperthyroid diagnosis:

Is the cat currently on methimazole? Circle: YES NO If yes, any reactions to methimazole:

Imaging:

Chest radiographs (if HR >220, murmur, gallop rhythm, or dyspnea / tachypnea):

Echocardiography:
Current medications and dosages (please include herbal / homeopathy):

Is this cat eating a prescription diet? YES NO Type:

Referring Doctor: Referring Hospital:

You may Fax this form, with any attachments, to Cat Specialist at 303-663-2333