Patient Questionnaire

Patient Symptom Questionnaire

Please DO NOT complete if your appointment is further than 1 month.
If your pet is experiencing an emergency, please contact us.

First Name

Last Name

Best Contact Number For Today:

Email Address

Reason for your pet’s appointment

Date/Time of your appointment

Pet's Name

Does your pet have a heart murmur?

Does your pet cough at home?

If yes, how often?

If yes, describe the level of difficulty?

If your visit today is for a recheck, has your pet's cough progressed since your last visit?

Do you feel that your pet has labored breathing, or uses an extra effort to breathe?

Does your pet seem to have exercise intolerance or does he/she get tired easily?

Yes No

Has your pet ever had a collapsing or a fainting episode? If yes, how many?

Has your pet had bloodwork within the past 30 days?

If yes, please list where.

What heartworm prevention is your pet taking?

List all medications your pet is currently taking, include: medication name, strength, amount given and frequency. Please indicate if you need any refills.

What type of food is your pet currently eating? Please include brand and formula.

How is your pet's appetite?

Does your pet have any other major medical conditions?

What is your pet’s Sleeping Respiratory Rate?

Notes/Comments/Concerns

Help us build our Facebook Page and Website. The purpose of photograph use is client outreach and web expansion. I agree that Veterinary Cardiopulmonary Care Center may use such photographs of my pet(s) with or without my pet’s first name for any lawful purpose, including for example such purposes as publicity, illustration, advertising and Web content. Please note, the above permission does not guarantee a photo of your pet will be taken or used. Thank you for helping with client education and outreach!

Photo Release Authorization

I approve I disapprove

Patient Symptom Questionnaire

Please DO NOT complete if your appointment is further than 1 month.If your pet is experiencing an emergency, please contact us.

Please DO NOT complete if your appointment is further than 1 month.
If your pet is experiencing an emergency, please contact us.