Cardiology History Questionnaire Cardiology Pre-Consult Form Client Name* First Last Pet Name* First Last Appointment Date* Date Format: MM slash DD slash YYYY Current Problem(s) and Medical History*Please indicate the main reason for coming in today:Diet HistoryWhat is your pet's diet?*CannedDryWhat is the brand?*Treats:*Table Food:*Changes in Normal ActivityPlease check any that applyAppetite:* Normal Increased Decreased Describe:Weight:* Normal Increased Decreased Describe:Water Intake:* Normal Increased Decreased Describe:Urination:* Normal Increased Decreased Describe:Bowel Habits* Normal Increased Decreased Describe:Diarrhea* None Daily Weekly Intermittent Describe:Vomiting:* None Daily Weekly Intermittent Describe:Exercise* Normal Increased Decreased Describe:Coughing* None Daily Weekly Intermittent Describe:When did the cough begin:Frequency of the cough:Has the cough: Worsended Improved Stayed the same n/a Character of the Cough Harsh Honking Wheezing Soft Wet Ends with gag Productive n/a Cough occurs: At night In the morning After activity/excitement After drinking Anytime n/a Has your pet had any treatment for the cough?YesNon/aIf yes, please specify:Was there any improvement following the treatment?Difficult/Rapid Breathing* None Daily Weekly Intermittent Describe:If yes, does the rapid breathing occur at a specific time of day?Respiratory Rate at Rest:*Breaths per minuteVoice/Bark Change:*YesNoDescribe:Collapse Episodes:*YesNoIf yes, please answer the questions below: How many collapsing events have occurred?List dates:Event occurred with:ExcitementActivity/ExerciseRestCoughPlease describe the event:How long did the event last?How long did it take for your pet to return to normal afterwards?Was there any abnormal behavior(s) before or after the event?Please describe: Are there any concurrent medical problems (eg. Diabetes)?*Medications & PreventativesCurrent Medications:*List all current medications including strength and frequency of administration Do you need any refills?*YesNoList Refills:Heartworm Prevention:*YesNoBrand:*Date of last heartworm test:*Test Results:* Positive Negative NameThis field is for validation purposes and should be left unchanged.
