Pre-Consult Questionnaire (NEW PATIENTS) | Gulf Coast Veterinary Cardiology

Client Name*

First Last

Co-owner's Name

First Last

Contact Email*

Phone (cell)*

Consent to receive text messages*

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Phone (home)

Co-owner's Phone

Address*

Street Address Address Line 2 City State ZIP Code

Pet Name*

Please upload a current photo of your pet:

Date of birth*

Gender*

Male/Intact
Male/Neutered
Female/Intact
Female/Spayed

Species*

Dog
Cat

Breed*

Primary care veterinary clinic name*

Date completed*

What is the reason that your pet needs to see a cardiologist?*

When was this concern first noted?*

Has your pet seen a cardiologist before?*

If yes, how long ago?

Has your pet been diagnosed with a heart murmur?*

When was it first diagnosed?

Has your pet been diagnosed with any other diseases?*

Did your veterinarian note any areas of fluid accumulation?*

If yes, location (i.e. lungs, chest, abdomen)

Current Medications – IMPORTANT

CLICK "+" TO LIST ADDITIONAL MEDICATIONS

*

Medication name	Form (tablet, capsule, liquid, etc)	Strength (mg)	Amount given each dose (# of tabs, caps, ml)	Frequency (number of times per day the medication is given)

CLICK "+" TO LIST ADDITIONAL MEDICATIONS

Recent bloodwork*

Yes
No
Unknown

Recent chest x-rays*

Yes
No
Unknown

Coughing/hacking?*

Yes
No

When did it start?

How often?

Describe sound (wet, dry, honking, etc.)

Worse with activity/excitement

Yes
No
Unknown

Worse at certain times of day

Yes
No
Unknown

If yes, when?

Is the cough

Worse
Stable
Improving

Rapid breathing while at rest*

Yes
No

When did it start?

Resting/sleeping breathing rate (if known)

Labored breathing/increased breathing effort?*

Yes
No

When did it start?

Is the breathing effort getting worse?

Yes
No

Exercise intolerance (not wanting to go on walks, not playing like normal, unable to jump or use stairs)?*

Yes
No

When did it start?

Collapse episodes*

Yes
No

When did the episodes first start?

How often?

Date of last episode

Any triggers (i.e. excitement/exercise, cough)?

Duration of episodes?

Does your pet lose consciousness?

Yes
No

Does your pet lose bladder control (urinate) during an episode?

Yes
No

Does your pet lose bowel control (defecate) during an episode?

Yes
No

Does your pet “paddle” their legs during an episode?

Yes
No

Are your pet's legs rigid/stiff during an episode?

Yes
No

Does your pet twitch (face or body) during an episode?

Yes
No

Does your pet have any unusual eye movements during an episode?

Yes
No

Does your pet return to normal quickly (within seconds to a few minutes)?

Yes
No

Any unusual behavior between episodes (head pressing, circling, appearing confused)?

Yes
No

Vomiting*

Yes
No

Date of onset and frequency?

Diarrhea*

Yes
No

Date of onset and frequency?

Urination*

No change
Increased
Decreased

Drinking*

No change
Increased
Decreased

Appetite*

No change
Increased
Decreased

Energy level*

No change
Increased
Decreased

Weight*

No change
Increased
Decreased

Painful*

No change
Increased
Decreased

List location of pain

Current Diet (including brand of commercial pet food, treats and human food)*

Is the diet grain-free?*

Yes
No

Travel*

Yes
No

Where/when

Heartworm Test*

Yes
No

Date*

Result*

Negative
Positive

Is your pet on consistent heartworm preventative?*

Yes
No

Tick exposure*

Yes
No
Unknown

How long have you had your pet?*

Where did your pet come from?*

Breeder
Rescue group
Animal shelter
Other

Is your pet*

Indoor
Outdoor
Both

Has your pet shown any aggression while visiting a vet hospital or towards other animals?*

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