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*YesNoUnknownRecent chest x-rays*YesNoUnknownCoughing/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 rest*YesNoWhen did it start?Resting/sleeping breathing rate (if known)Labored breathing/increased breathing effort?*YesNoWhen 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 consciousness?YesNoDoes your pet lose bladder control (urinate) during an episode?YesNoDoes your pet lose bowel control (defecate) during an episode?YesNoDoes your pet “paddle” their legs or twitch during an episode?YesNoDoes your pet return to normal quickly (within seconds to a few minutes)?YesNoAny unusual behavior between episodes (head pressing, circling, appearing confused)?YesNoVomiting*YesNoDate of onset and frequency?Diarrhea*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)*Is the diet grain-free?*YesNoTravel*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
