PAUS CLINICAL INFORMATION FOR SCHEDULED PATIENTS

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

CARDIAC (ECHOCARDIOGRAM)ABDOMINAL ULTRASOUNDBI-CAVITY ULTRASOUNDURINARY SYSTEM ONLYOther
Scheduled Date of Service*

MonthDayYear
Veterinary Hospital*
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*
**If abdomen ultrasound, patient should be NPO from supper meal the night before (unless diabetic or other). Also, a reasonably full bladder is desirable.
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
Increased Respiratory RateIncreased Respiratory EffortExercise IntoleranceCollapse/SyncopeOther (please explain)
Please explain episode(s)*
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.)?*

Yes.No.
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*

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

YesN/A
Current medications and dosages:*
Radiography Results:
Should be Empty: