PAUS CLINICAL INFORMATION FOR SCHEDULED PATIENTS

CLINICAL INFORMATION FOR SCHEDULED PATIENTS
Asterisks denote a required field*
Requested Exam*

CARDIAC (ECHOCARDIOGRAM)CARDIAC (ECHOCARDIOGRAM) + ECGECG ONLYHOLTER MONITORING (WITH INTERPRETATION)ABDOMINAL ULTRASOUNDBI-CAVITY ULTRASOUNDBI-CAVITY ULTRASOUND + ECGURINARY SYSTEM ONLYGASTROINTESTINAL SYSTEM ONLYTHYROID / PARATHYROIDCRYPTORCHID (WITH INTERPRETATION)BRIEF ULTRASOUND (WITHOUT SPECIALIST INTERPRETATION)PREGNANCY (CHECK FOR VIABILITY)STATOther
* IF ABDOMINAL ULTRASOUND IS REQUESTED, THE PATIENT SHOUDL BE NPO FROM SUPPER MEAL THE NIGHT BEFORE (UNLESS DIABETIC OR OTHER). ALSO, A REASONABLY FULL BLADDER IS DESIRABLE.
Requested Date of Service*

MonthDayYear
Veterinary Hospital*
Veterinary Hospital Name Corrected
Veterinary Hospital Phone (Main Number) THIS IS YOUR UNIQUE IDENTIFIER*
Hospital Email*
Requesting Doctor (first, last, credential)*
Pet Name (first, owner's last)*
Requesting Doctor Name (First and Last - please add credentials) *
PATIENT'S Full Name (First and Last)*

PATIENT'S First NamePATIENT'S Last Name
Hospital Staff Pet
Species

CanineFelineMustelid FerretOther Species
Breed*
Age*
Date of Birth (approximate if unknown)
Sex*
Weight*
Weight*
Blood Pressure (always with echocardiogram)
Cardiac Murmur*

YesNo
Grade range of Murmur (check all that apply)*

Grade l/VlGrade ll/VlGrade lll/VlGrade lV/VlGrade V/VlGrade Vl/Vl
Are there any clinical signs*

YesNo
Cardiac signs, symptoms, or conditions:

Increased Respiratory RateIncreased Respiratory EffortExercise IntoleranceCollapse/SyncopeOther (please explain)
Please explain episode(s)*
Abdominal / Small Parts (signs, symptoms, or conditions):*
Previous Ultrasound Deprecated*

YesNo
Previous Ultrasound*

YesNo
Previous Ultrasound Date*
** Please have the prior ultrasound report available on the day of the ultrasound appointment.
Has there been any update in the patient's clinical status since the previous study (e.g., new diagnoses, emergency room visits, changes or additions to medications, etc.)? (Depracated)*

Yes.No.
Has there been any update in the patient's clinical status since the previous study (e.g., new diagnoses, emergency room visits, changes or additions to medications, etc.)?*

YesNo
Please describe or add to the history below.
INFORMATION BELOW TO BE PROVIDED BY DOCTOR, PLEASE
History / Clinical Presentation / Pertinent Past History / Physical Exam Findings: *
Abnormal CBC/Chem/UA*

YesNoPending
Abnormals only (with values, eg, ALT 285, creat 2.6) *
Current medications*

YesN/A
Current medications and dosages:*
Radiography Results:
Technologist
Performing Technologist
Veterinary Hospital
Exam Status

CompletedCanceledNo ShowStudy AbortedStudy Aborted and Rescheduled
Date Study Performed

MonthDayYear
Date
Charge Billed
Should be Empty: