Pre-visit Questionnaire Client Name(Required) First Last Email(Required) Phone (mobile)(Required)Phone (home)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co-owner Name First Last Co-owner PhoneCo-owner Email Pet Name(Required)DOB(Required) MM slash DD slash YYYY Species(Required)SelectDogCatBreed(Required)Sex(Required)SelectMale intactMale neuteredFemale intactFemale spayedPrimary Care Veterinarian(Required)What is the reason that your pet needs to see a cardiologist?(Required)When was this concern first noted?(Required)Has your pet seen a cardiologist before? If yes, when?(Required)Has your pet been diagnosed with a heart murmur? If yes, when?(Required)Has your pet been diagnosed with any other conditions or diseases?(Required)Did your veterinarian note any areas of fluid accumulation? If yes, where? (heart, chest, abdomen)(Required)Current Medications — IMPORTANTPlease click “+” to add additional medications. Medication Name / Form (liquid, capsule, tablet) / Strength (mg) / Dose / FrequencyCurrent Medications — IMPORTANT(Required)Medication NameForm (liquid, capsule, tablet)Strength (mg)DoseFrequency Add RemovePlease click “+” to add additional medications.Health & Lifestyle HistoryRecent bloodwork(Required) Yes No UnknownRecent chest x-rays(Required) Yes No UnknownCoughing/hacking?(Required) Yes NoRapid breathing while at rest(Required) Yes No Resting/sleeping breathing rate (if known)Labored breathing/increased breathing effort?(Required) Yes NoExercise intolerance (not wanting to go on walks, not playing normally, unable to jump or use stairs)?(Required) Yes NoCollapse episodes(Required) Yes NoVomiting(Required) Yes NoDiarrhea(Required) Yes NoUrination(Required) No change Increased DecreasedDrinking(Required) No change Increased DecreasedAppetite(Required) No change Increased DecreasedEnergy level(Required) No change Increased DecreasedWeight(Required) No change Increased DecreasedPainful(Required) No change Increased DecreasedLocation of painCurrent Diet (including brands of commercial pet food, treats, and human food)(Required)Is the diet grain-free?*(Required) Yes NoAny travel? Yes NoWhere and when?Heartworm Test(Required) Yes NoDate of testIs your pet on consistent heartworm preventative?(Required) Yes NoTick exposure(Required) Yes No UnknownHow long have you had your pet?(Required)Where did your pet come from?(Required) Breeder Rescue Group Animal Shelter OtherIs your pet(Required) Indoor Outdoor BothHas your pet shown any aggression while visiting a vet hospital or towards other animals?*Payment Policy(Required) I acknowledge and understand the following policy: Payment is due at the time of service. We accept cash, checks, and all major credit cards.Δ
