Pre-Consult Questionnaire Client Name* First Last Co-owner's Name First Last Contact Email*Phone (cell)*Phone (home)*Co-owner's PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet Name*Please upload a current photo of your pet:Date of birth*Gender*Male/IntactMale/NeuteredFemale/IntactFemale/SpayedSpecies*DogCatBreed*Primary care veterinary clinic name*Date completed* Date Format: MM slash DD slash YYYY Completed by*OwnerVeterinarianWhat 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*Medication NameDose (mg)Amount given (tab/cap/ml)How Often Click "+" to add additional medicationsRecent bloodwork*YesNoDid bloodwork include thyroid level*YesNoRecent chest x-rays*YesNoRecent blood pressure*YesNoCoughing/hacking*YesNoWhen 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 episodes*YesNoWhen 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)YesNoDiarrhea*YesNoDate of onset and frequency?Vomiting*YesNoDate of onset and frequency?Urination*No changeIncreasedDecreasedDrinking*No changeIncreasedDecreasedAppetite*No changeIncreasedDecreasedEnergy level*No changeIncreasedDecreasedWeight*No changeIncreasedDecreasedPainful*No changeIncreasedDecreasedList location of painCurrent Diet (including treats and human food)*Travel*YesNoWhere/whenHeartworm Test*YesNoDate*Result*NegativePositiveMonthly heartworm preventative*YesNoTick exposure*YesNoUnknownHow long have you had your pet?*Where did your pet come from?*BreederRescue groupAnimal shelterOtherIs your pet*IndoorOutdoorBothHas your pet shown any aggression while visiting a vet hospital or towards other animals?*CAPTCHA
