Diabetic Admit Sheet - Borash Veterinary Clinic

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Borash Veterinary Clinic
79 Prospect Street
Peabody, MA 01960
(978) 531-8713 ~ Fax (978) 532-1046
Web - borashvet.com ~ E-mail - [email protected]
DIABETIC ADMIT SHEET
Pet’s Name: ________________________ Owner’s Name: ______________________
Date: ____/____/____
Date of last visit: ____/____/____
Type of Insulin
& Syringes:
Did pet get insulin this AM? YES / NO How much? __________What time? __________
Did pet eat this AM? YES / NO How much? __________
**Appetite 1 2 3 4 5
What time? __________
(1= very finicky 5=great appetite)
**Water Intake 1 2 3 4 5
**Activity Level 1 2 3 4 5
(1= bowl always seems full 5=water bowl always empty)
(1= sleeps all the time 5=great amount of energy)
Regular Diet: ______________________________________________________________________________
Treats: ___________________________________________________________________________________
Regular Exercise: __________________________________________________________________________
I certify that I own and assume financial responsibility for the above-described animal. I do hereby consent and
authorize the Borash Veterinary Clinic and its staff to hospitalize this animal and to administer, medications,
tests, procedures, that the doctor deems necessary for the health, safety and well being of the above described
animal while it is under their care and supervision.
Owners Signature:____________________________________________Date:_________________________
****************************(For BVC staff member to fill out)*****************************
Blood Glucose Curve
Weight: _____________
Baby scale / Rm 1 / Rm 3
400
350
300
250
200
150
100
50
8a____ / 9a____ / 10a____ / 11a____ / 12p____ / 1p____ / 2p ____ / 3p ____ /4p ____ / 5p ____ / 6p ____
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