Mobile Ultrasound Patient Form

Clinic Information

Veterinary Practice Name*

Doctor Name:*

Primary Email Address*

example@example.com

Additional Email Address(es)

Fax Number(s)

Patient Information

Patient First Name*

Patient Last Name*

Species*

Gender*

Breed*

Date of Birth*

Date

Weight (lbs)*

Ultrasound Region(s)

Please check all that apply.*

Submit with X-rays?*

YesNo

If Yes, How many images?

Who would you like to review X-Rays?

RadiologistCardiologist

Submit with ECG?*

YesNo

STAT Requested?*

Yes. Additional charge of $85No

Specific Specialist Requested?*

YesNo

If Yes, please list preferred Specialist(s).

Pertinent Clinical History

Brief History

Echocardiogram Brief History

Guidelines for cardiology history submission: &#13;&#10;&#13;&#10;- Purpose for study submitted &#13;&#10;&#13;&#10;- Any murmur present (please state none if none noted)? &#13;&#10;&#13;&#10;- Any clinical signs? - If none noted, please state this - Please describe the clinical signs (e.g., characteristics, frequency, any progression/improvement), if present - If patient has received any medications for clinical signs, please state this (including drugs/doses) and include any response to therapy &#13;&#10;&#13;&#10;- If collapsing is reported, please provide details (frequency of events; triggers for the events such as, coughing, excitement/exercise; specific characteristics of the event, such as limb movement, chewing motion, nystagmus; recovery such as duration of time before appearing normal, any vision/mentation changes during recovery) if known&#13;&#10;&#13;&#10;- Please list current medications with doses (especially for cardiac medication). It is very difficult, if not impossible, to make recommendations for medical therapy if current drugs/doses are not provided - If cardiac medications are being given, please state dates when started and why - If cardiac medications are being given, please state if any changes have been made in dosing (when/what the change was) and any changes in clinical condition following change in dose - If furosemide is being administered, please state details of past diagnosis of CHF (how diagnosed, when, how many episodes) &#13;&#10;&#13;&#10;- Heartworm status (prevention administration, testing) &#13;&#10;&#13;&#10;- Type of diet (especially if nontraditional) - Any ancillary testing performed (e.g., Doppler/oscillometric blood pressure, labwork, proBNP); include results when applicable &#13;&#10;&#13;&#10;- Any concurrent noncardiac medical problems (e.g., chronic renal failure, hyper- or hypothyroidism) - &#13;&#10;Please link any past radiographic reports (if for thorax) or echocardiographic reports or state dates/reports to be reviewed if there are past VitalRads studies for the particular patient &#13;&#10;&#13;&#10;** Please note that the above is the ideal information to be provided for most cardiology cases. This does not mean that the case will not be read if some of this information is missing in the history provided. However, if there is information missing that is considered to be crucial to interpretation of the case or for providing treatment recommendations (e.g., current doses of cardiac medication), the case may be placed on hold until this information can be obtained from the clinic. The goal is to obtain as accurate of a history as possible in order to provide the best possible assessment and recommendations for your patient.

Working Diagnosis and/or Comments*

Private comments for Specialist

Sedation given?*

YesNo

If yes, please list sedation given.

Is patient currently on any medications or supplements?*

YesNo

If yes, please list all medications and supplements.

Heart Murmur*

YesNo

If Yes, please list grade.

Abnormal Labs*

Anything else you would like to share regarding this patient?

Comments

File Upload