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

Client Name*

First Last

Contact Email*

Phone (cell)*

Phone (home)

Address*

Street Address Address Line 2 City State ZIP Code

Co-owner's Name

First Last

Co-owner's Phone

Co-owner's Email

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?*

Pharmacy Preference*

If a prescription cardiac medication is recommended for your pet, you have different options of how to obtain the medication (select one):

Gulf Coast Veterinary Cardiology’s online pharmacy with direct-to-home shipping and competitive pricing
Written prescription to have filled at your primary care veterinary clinic or the pharmacy of your choice

Outside Pharmacy Policy*

I acknowledge and understand the following policy:

GCVC will no longer call, fax, or email prescriptions to outside pharmacies, including online pharmacies such as Chewy or 1800PetMeds – it is the owner’s responsibility to submit the written prescription(s) to these pharmacies.

If you choose to have the prescription filled with a local human pharmacy, please ensure that the pharmacy will accept a prescription WITHOUT an NPI number or DEA license number (Dr. Schlater’s veterinary license numbers and contact information are printed on the prescription, and this is all that is legally required for a veterinarian to prescribe non-controlled medications.) GCVC will not respond to inquiries from pharmacies requesting NPI or DEA numbers.

Late Policy*

I acknowledge and understand the following policy:

If you arrive 10-20 minutes past your scheduled appointment time, we will try to see your pet. However, there will not be time for Dr. Schlater to review the test results in-person. Results will be EMAILED to you.

If you arrive 20 or more minutes past your scheduled appointment time, out of respect for the time of other clients on our schedule, you will not be seen, and any deposit will be forfeited.

Payment Policy*

I acknowledge and understand the following policy:

Payment is due at the time of service. We accept cash, checks and all major credit cards. We DO NOT accept Care Credit or Scratchpay.

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