Cardiology Recheck Questionnaire



Pet's Name: *

Owner's Name: *

Owner's Email: *

NorthStar VETS Location: Robbinsville     Maple Shade

How are your pet's 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

Medications

What current medications is your pet taking? Please list all name, dose and frequency if known.
(please list dose in milligrams if known):

Does your pet need any refills on any of his/her medications?

Yes     No

If yes, please note which medications

Would you like medications filled here or written prescriptions to fill at your local pharmacy?

NorthStar Vets     Pharmacy