Medical History: Cardiology Initial / Recheck
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Contact Information
Your name
*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Phone number to be reached at during your appointment
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(XXX) XXX-XXXX
Your pet's name
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Which veterinary hospital would you like us to send your records to after the visit?
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Typically, this is your primary (family) veterinarian.
Has your pet seen another cardiologist at a different hospital?
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Yes
No
Who?
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Name of cardiologist
Where?
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Name of hospital
What is the purpose of your visit?
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Initial Consultation
Recheck Appointment
What Symptoms/Diagnosis are you concerned about?
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When was this first noted/diagnosed?
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Since your last visit, has your pet’s symptoms:
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Resolved/Gotten better
Persisted the same
Gotten worse
Compared to normal, is your pet’s activity level:
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Decreased
Normal
Improved
Other
If "Other", please explain:
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How would you describe your pet's activity level?
Has your pet been coughing?
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Yes
No
What is the frequency per day?
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When did the coughing begin?
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Have you been monitoring the sleeping breathing rates?
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Yes
No
While your pet is at rest (sleeping), how many breaths per minute do you count?
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Breaths per minute
Do you feel that your pet is experiencing trouble breathing?
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Yes
No
If "Yes", please explain.
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Has your pet experienced any episodes of weakness or collapse?
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Yes
No
Has this occurred just once or multiple times?
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Just once
Multiple times
Please describe the episode of weakness or collapse.
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When did it happen? Was your pet doing anything beforehand? How long did it last for?
If "Multiple times", please elaborate:
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How frequently has this happened? Do you think that there has been an increase in the frequency of episodes?
What is the name of your pet’s diet?
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Have you fed your pet a diet that is labeled as “Grain-Free” within the last year?
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Yes
No
What is the name of the diet?
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Are you still giving this diet, or have you changed it?
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Still giving this diet
Changed to new diet
Does your pet have any food allergies? (We would like to offer treats during the appointment!)
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No known food allergies
Yes
Please do NOT give treats
What are your pet's food allergies?
*
Compared to normal, is your pet’s appetite:
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Decreased
Normal
Increased
Is your pet vomiting?
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Yes
No
If "Yes", please elaborate:
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When did this begin? Has it resolved? Were any treatments started for this?
Is your pet having diarrhea?
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Yes
No
If "Yes", please elaborate:
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When did this begin? Has it resolved? Were any treatments started for this?
Has your pet’s urination habits:
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Decreased
Stayed the same
Increased
Has your pet’s thirst:
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Decreased
Stayed the same
Increased
Does your pet receive a monthly heartworm preventative?
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Yes
No
Unsure
Has your pet been prescribed any medication? (Cardiac or other)
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Yes
No
If "Yes", which medication(s) is your pet taking?
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Please describe the strength of the tablet/capsule/liquid, how frequently you give the medication, and how many tablets/capsules/mL you give.
Have you been giving your pet supplements? (Cardiac or other)
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Yes
No
If "Yes", please elaborate:
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Which supplement(s) is your pet taking? How frequently?
Since starting these medications, has your pet’s condition:
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Improved
Worsened
Remained the same
Other
If "Other", please explain:
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Has your pet had an adverse reaction to any medications in the past?
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Yes
No
If "Yes", please explain:
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Which medication was it? What were the symptoms?
Do you have any dental procedures or surgeries planned for after this appointment?
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Yes
No
If "Yes", what procedure do you have planned?
*
Name of procedure
Is there anything else you think we should know? (Optional)
Examples: Other conditions/diagnoses, temperament, etc.
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