Pre-Consult Questionnaire Client Name First Last Contact EmailPhone (cell)Phone (home)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Pet NameDate of birthGenderMale/IntactMale/NeuteredFemale/IntactFemale/SpayedSpeciesDogCatBreedPrimary care veterinary clinic nameDate completed Completed byOwnerVeterinarianWhat 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 – IMPORTANTMedication NameDose (mg)Amount given (tab/cap/ml)How Often Click "+" to add additional medicationsRecent bloodworkYesNoDid bloodwork include thyroid levelYesNoRecent chest x-raysYesNoRecent blood pressureYesNoCoughing/hackingYesNoWhen did it start?How often?Describe sound (wet, dry, honking, etc.)Worse with activity/excitementYesNoUnknownWorse at certain times of dayYesNoUnknownIf yes, when?Is the coughWorseStableImprovingRapid breathing while at restYesNoWhen did it start?Resting/sleeping breathing rate (if known)Labored breathing/increased breathing effortYesNoWhen did it start?Is the breathing effort getting worse:YesNoExercise intolerance (not wanting to go on walks, not playing like normal, unable to jump or use stairs)YesNoWhen did it start?Collapse episodesYesNoWhen did the episodes first start?How often?Date of last episodeAny triggers (i.e. excitement/exercise, cough)?Duration of episodes?Does your pet lose consciousnessYesNoDoes your pet lose bladder control during an episode:YesNoDoes your pet lose bowel control during an episodeYesNoDoes your pet “paddle” their legs or twitch during an episodeYesNoDoes your pet return to normal quickly (within seconds to a few minutes)YesNoAny unusual behavior between episodes (head pressing, circling, appearing confused)YesNoDiarrheaYesNoDate of onset and frequency?VomitingYesNoDate of onset and frequency?UrinationNo changeIncreasedDecreasedDrinkingNo changeIncreasedDecreasedAppetiteNo changeIncreasedDecreasedEnergy levelNo changeIncreasedDecreasedWeightNo changeIncreasedDecreasedPainfulNo changeIncreasedDecreasedList location of painCurrent Diet (including treats and human food)TravelYesNoWhere/whenHeartworm TestYesNoDateResultNegativePositiveMonthly heartworm preventativeYesNoTick exposureYesNoUnknownHow long have you had your pet?Where did your pet come from?BreederRescue groupAnimal shelterOtherIs your petIndoorOutdoorBothHas your pet shown any aggression while visiting a vet hospital or towards other animals?
