Recheck Questionnaire (EXISTING PATIENTS) Recheck Questionnaire (EXISTING PATIENTS) Client Name* First Last Contact Email*Contact Phone*Address (if different from last visit) 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*Primary care veterinary clinic name (if different from last visit)Date completed* Date Format: MM slash DD slash YYYY Has your pet been diagnosed with any other diseases since his/her last visit? If yes, please provide details below.*Current Medications – IMPORTANTCLICK "+" TO LIST ADDITIONAL MEDICATIONS*Medication nameForm (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 MEDICATIONSBloodwork since last visit?*YesNoUnknownChest x-rays since last visit?*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 during an episode?YesNoAre your pet's legs rigid/stiff during an episode?YesNoDoes your pet twitch (face or body) during an episode?YesNoDoes your pet have any unusual eye movements 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 brand of commercial pet food, treats and human food)*Is the diet grain-free?*YesNoHeartworm test*YesNoUnknownDate*Result*NegativePositiveIs your pet on consistent heartworm preventative?*YesNoPharmacy Preference*Gulf Coast Veterinary Cardiology’s online pharmacy with direct-to-home shipping and competitive pricingWritten prescription to have filled at your primary care veterinary clinic or the pharmacy of your choiceIf a prescription cardiac medication is recommended for your pet, you have different options of how to obtain the medication (select one):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 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. In these cases, if an in-person or phone conversation is desired, a separate appointment will be scheduled and fees will apply. 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.CAPTCHA