If your pet has a scheduled appointment with Dr. Orr & East Coast Veterinary Cardiology, we ask that you complete this history form prior to your appointment.  Completing this form will help Dr. Orr’s evaluation of your pet by allowing him to understand the signs that you may be noting at home (including duration), knowing which medications your pet may be taking and knowing any other previous health issues your pet has had in the past.

Please be sure to include your name, email, and pet’s name (all required fields).  This form should only take a few minutes to complete.   There is an easy math question at the end of the history form to ensure you are human (and not a robot).  Thank you!

    Your Name (required)

    Your Email (required)

    Your Pet's Name (required)

    What is your pet's diet? (please note if labelled "Grain Free")

    Is your pet receiving up to date heartworm prevention?YesNo

    Please note any changes to your pet's:

    Appetite
    NormalDecreasedIncreased

    Water Intake
    NormalDecreasedIncreased

    Weight
    NormalDecreasedIncreased

    Urination
    NormalDecreasedIncreased

    Exercise Capacity
    NormalDecreasedIncreased

    Coughing?
    NoneRare (several times monthly)Intermittent (several times weekly)Daily (occasional)Daily (frequent)

    Vomiting?
    NoneRareWeeklyDaily

    Diarrhea?
    NoneRareWeeklyDaily

    If your pet is coughing, when did it first start (days, weeks, months ago)?

    If your pet is coughing, when does it generally occur (check all that apply)?
    First thing in the morningIn the middle of the nightAfter drinking or eatingAfter playing/excitementAt rest

    If your pet is coughing, what is the character of the cough (check all that apply)?
    HackingSoftHonkingWheezyWet soundingEnds with a retch/gag

    If your pet is coughing, any previous treatments for the cough? Did they help?

    Is your pet having any difficulty breathing?
    NoneDailyWeeklyIntermittent

    Describe any difficulty breathing you have noticed with your pet (such as only happens at night, happens only after exertion):

    What is your pet's resting respiratory rate? You may visit under 'For Pet Owners' information on how to acquire a resting respiratory rate.

    Is your pet having any fainting episodes?
    NoneDailyWeeklyIntermittent

    If your pet is fainting, how many have you witnessed?

    If your pet is fainting, what happened just prior to the fainting spell?
    NothingExcitementExerciseCoughingVomiting or defecating

    If your pet is fainting, during the episode what did you notice about your pet? (check all that apply)
    Limp/weakStiff/rigidUnconsciousConsciousTremblingPaddling/moving legsDroolingUrinatedDefecated

    If your pet is fainting, how long did the episode last and how long did it take for them to return completely to normal?

    If your pet is currently taking any medications, please list the name, strength and dosage (example: Furosemide 40 mg twice daily):

    List any other significant health problems that your pet has had in the past:

    List any other concerns you have about your pet (other signs or changes that you are noting)

    Thank you for completing this history form prior to your pet's cardiac evaluation. This information is very helpful to us and provides us with extra background about your pet.