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Recheck Patient History Form

Thank you for allowing us to continue your pets care! In an effort to make sure your experience with our hospital is as efficient as possible, we have attached a few questions regarding your pet’s medical history that we ask that you answer prior to your scheduled recheck appointment. Should you have any questions, please feel free to include them in this email. If your clinic gave you any paper records, and or a disk with x-rays please bring those with you or email them to cardiology@gcvs.com.
Client Name*
Patient Name*
In your own words, can you tell us the primary reason for this visit?*
Has your pet been to any other veterinary clinic besides the referring clinic since we saw your pet last? If so, please specify so we can ensure that we have all pertinent medical records.*
Overall, how is your pet doing?*
Has there been any coughing or change to coughing since last visit? If yes, how long has this been happening, and does anything trigger the coughing (e.g. excitement, etc.) or is there a certain time of day it occurs (e.g. first thing in the morning, when getting up from lying down, etc.)?*
Has your pet had any collapsing or fainting episodes, or an increase/decrease in historical episodes? If yes, please describe event and recovery (e.g. occurs with excitement; fast recovery versus dazed or post-ictal phase, how long the event lasts, how long they have been occurring, and how often they occur).*
How is your pet’s activity level since the last visit? If decreased, how long has it been decreased?*
Have you noticed any exercise intolerance? If yes, please describe it and how long/how often it has been happening.*
Does your pet seem to breathe comfortably when sleeping?*
- Yes
- No
Are you obtaining a resting respiratory rate? If yes, what have you been getting?*
a. How is your pet’s appetite? Has there been a change in appetite recently? If yes, please specify.*
What food is being fed (brand of food, as well as flavor and formulation [dry versus canned])?*
How long has your pet been on this food? If not life-long, what food was your pet on before?*
Is your pet up to date on heartworm and flea prevention? Please list which preventatives are being taken.*
a. Please list all medications and supplements your pet is currently taking. Please include the doses and how often you are giving each medication, even if we are the prescribing clinic.*
Do you need refills on your pet's medications? If yes, please specify which.*
a. Please list your preferred pharmacy, in case we need to call medications into an outside pharmacy (i.e. your local pharmacy, not a veterinary pharmacy).*
We often use treats for encouragement and rewards! Is your pet allowed to have treats/peanut butter? If not, please bring with you a small amount of their favorite treats or kibble.*
- Yes
- No, I'll bring my own treats
Name
This field is for validation purposes and should be left unchanged.