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Pre-Consult Form: Cardiology

Cardiology Pre-Consult Form

"*" indicates required fields

Client Name*

First Last

Pet Name*

First Last

Appointment Date*

MM slash DD slash YYYY

Current Problem(s) and Medical History*

Please indicate the main reason for coming in today:

Diet History

What is your pet's diet?*

Canned

Dry

What is the brand?*

Treats:*

Table Food:*

Changes in Normal Activity

Please check any that apply

Appetite:*

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?

Yes

n/a

If 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 minute

Voice/Bark Change:*

Yes

Describe:

Collapse Episodes:*

Yes

If yes, please answer the questions below:

How many collapsing events have occurred?

List dates:

Event occurred with:

Excitement

Activity/Exercise

Rest

Cough

Other

Please 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 & Preventatives

Current Medications:*

List all current medications including strength and frequency of administration

Do you need any refills?*

Yes

List Refills:

Heartworm Prevention:*

Yes

Brand:*

Date of last heartworm test:*

Test Results:*

Positive

Negative

This field is for validation purposes and should be left unchanged.

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