Pre-Consult Form: Cardiology "*" indicates required fields Client Name* First Last Pet Name* First Last Appointment Date Month Day Year Current Problem(s) and Medical History*Please indicate the main reason for coming in today:Diet HistoryWhat is your pet's diet?* Canned Dry What 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? Yes No 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 No Describe: Collapse Episodes:* Yes No 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 & PreventativesCurrent Medications:*List all current medications including strength and frequency of administration Add RemoveDo you need any refills?* Yes No List Refills: Heartworm Prevention:* Yes No Brand:* Date of last heartworm test:* Test Results:* Positive Negative CommentsThis field is for validation purposes and should be left unchanged.