Radioiodine Therapy Checklist for Referring Veterinarians

To help us better treat your patients, please take a few moments to complete the following patient information sheet and checklist.

Please attach any additional information you think we should know about your patient.

REFERRING VETERINARIAN INFORMATION

Name of Referring Veterinarian *

Name of Referring Hospital *

Phone Number *

Email Address *

PATIENT INFORMATION

Client's Name *

Client's Email Address *

Client's Phone Number *

Patient's Name *

CHECKLIST

The following are required within 1 month of radioiodine therapy: CBC, chemistry panel, T4 (quantitative) and urinalysis.

*If your patient has a cardiac arrhythmia or loud murmur, ECG/ultrasound/radiographs are suggested (unstable cardiac patients would be considered high-risk for the procedure)

*If palpable abdominal masses or changes in bloodwork outside of what is expected for being hyperthyroid, radiographs, and/or ultrasound are suggested

*Total body survey radiographs are recommended but not required for all patients

Please note your patient’s pre-treatment T4 level *

Date of pre-treatment T4 Level *

Highest recorded serum T4 level *

Date of highest recorded T4 level *

Please grade your patient’s hyperthyroid status based on the severity of clinical signs (mild, moderate, severe) *

	Severity of Clinical Sign
Weight loss
Polyuria
Polydipsia
Heart rate (provide bpm)
Heart murmur (grade)
Tachypnea/panting
Hyperexcitability

*If a cat’s heart rate is greater than 240 bpm, please initiate atenolol therapy prior to referral.

Please assess appetite: *

*If your patient is on a prescription diet, please instruct the owner to bring enough of the cat’s food for approximately 10 days.

Approximate size of thyroid nodule - RIGHT SIDE *

Approximate size of thyroid nodule - LEFT SIDE *

Does this patient require any medication while hospitalized for radioiodine therapy? *

Please specify the drug name, dosage, and frequency of administration. If atenolol is required, please dispense enough for 2 weeks. Also, please instruct the owner to bring medications with them at the time of admission.

Is there a concurrent disease that may affect this patient during hospitalization? *

Please comment on patient’s personality: *

*Fractious patients may require sedation prior to radioiodine injection to avoid a radiation spill.

Does this patient suffer from anorexia when stressed or hospitalized? *

Yes
No
Unsure

Any other comments that may be helpful?

Thank you for your referral, and for helping ensure we have all the information needed to treat your patient successfully.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Radioiodine Therapy Checklist for Referring Veterinarians

REFERRING VETERINARIAN INFORMATION

PATIENT INFORMATION

CHECKLIST

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