Cardiology New Appointment Questionnaire



Pet's Name: *

Owner's Name: *

Owner's Email: *

NorthStar VETS Location:

Robbinsville     Maple Shade

Why is your pet coming to see us?(presenting complaint)

Symptoms (Elaborate and include duration as needed)

Appetite     Normal     Decreased     Increased

Please Explain

Thirst     Normal     Decreased     Increased

Please Explain

Stools     Normal     Decreased     Increased

Please Explain

If abnormal, please describe color and consistency. Any blood, mucus, straining, increased
frequency or increased urgency to defecate

Urinations     Normal     Decreased

If abnormal, please describe color, any blood, and straining, leaking,accidents in the house,
increased frequency or urgency to urinate

Vomiting?     Yes     No

If yes, please describe what the vomit looks like and how often your pet is vomiting

Coughing/Hacking Cough?     Yes     No

If yes, please describe how often, if coughing is worse at any certain time of the day and if
the cough is worsened by exercise or excitement

Fainting/Collapse?     Yes     No

If yes, please describe how frequently this has occurred, how long the episodes last,
what happened right before the episode and how long does it take for your pet to return to "normal"

Labored Breathing?     Yes     No

(If yes, please describe when this occurred, was any medication given or prescribed to help
improve the breathing?

Activity Level     Normal     Decreased     Increased

Please describe when you first noticed a change in your pet's activity level

Please describe any other symptoms not listed above:

Have any of the following diagnostic tests been performed?

Blood Work:     Yes     No

If yes, when?

EKG (electrocardiogram):     Yes     No

If yes, when?

Radiographs (X-Rays):     Yes     No

If yes, when?

Echocardiogram (cardiac ultrasound):     Yes     No

If yes, when?

Prior Medical History

Does your pet have any current/past medical problems, prior surgeries
(other than spay/neuter) or a prior need for hospitalization?

Is your pet up-to-date on his/her rabies vaccination?     Yes     No

Cats

Has your cat been tested for: FeLV (Feline Leukemia Virus)

Yes     No     Unsure

If yes, when?

Has your cat been tested for: FIV (Feline Immunodeficiency Virus)

Yes     No     Unsure

If yes, when?

Is your cat:     Indoor Only     Indoor/Outdoor     Outdoor Only

Medications

List all medications given to your pet including:

Heartworm preventative:     Yes     No

If yes, last given?

Flea/tick preventative:     Yes     No

If yes, last given?

Vitamins/other supplements:     Yes     No

If yes, last given?

Please list all medications given to your pet, ie: name/dose/frequency
(please list dose in milligrams if known):

Do you feel that any of these medications have helped any of your pet's symptoms?

Yes     No

If yes, please explain which ones helped and how

Please include any important information not covered on this
questionnaire you would like the doctor to know: