Echocardiography Referral Veterinary Clinic/Hospital name * Veterinary Clinic/Hospital email address * Referring Veterinarian * Patient's name * Owner's name * First Name Last Name Owner's email Mandatory for Referral Outpatient (AVAH/OAESH) Preferred Date & Time Please indicate preferred day of the week, and AM or PM Type of pet * Dog Cat Other Sex of pet * MN M FS F Age of pet * Years Months Weeks Age of pet * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Breed of pet * Weight (Kg) * Brief History * Indications/clinical signs Heart Murmur Abnormal Breathing Coughing Arrhythmia or ECG abnormality Exercise intolerance Syncope/collapse Acute onset paralysis History of grain free or other atypical diet Pre-chemotherapy study Heartworm positive status Other/not listed Other, if not listed Is there a Heart Murmur present? Yes, New Yes, Chronic No If a heart murmur present, is it: Systolic Diastolic Continuous If a murmur is present, please choose the location: Left Apical Left Basilar Left Parasternal Right Apical Right Basilar Right Parasternal All parts of the chest Heart Murmur Grade * None 1 2 3 4 5 6 Is there an Arrhythmia present? Yes No If an arrhythmia is present, please describe (ie. irregularly irregular, regularly irregular, etc, type if known) Body Condition Score * 1 is the most thin and 9 is the most overweight, with 4-5 representing ideal conditiong 1 2 3 4 5 6 7 8 9 Any recent changes in body condition? * Stable Recent weight gain Recent weight loss Systolic Blood Pressure result Total T4 result ProBNP result Creatinine results Heartworm test results Please describe any relevant prior treatments the patient received for the current clinical signs Please list the patient's current cardiac medications Include drug name, dosage, administration route and frequency Please describe the patient's response to these cardiac medications, if any Please list any other medications the patient is taking, including supplements Include drug name, dosage, administration route and frequency, if possible Do you need comments on anesthesia for a procedure planned in the short-term future? * Yes No If yes, what is the name of the procedure? FAS Fear, anxiety, stress 1 2 3 4 5 Sedation Protocol * Please provide a sedation protocol, in the event required Additional Information Triage * Routine (within 2 weeks) Semi-urgent (within 2-4 days) Emergency (within 36 hours) Thank you!
