Patient Information Form

This form is for veterinarians only. If you are a pet owner looking to book an ultrasound for your pet, please contact your local veterinarian to schedule an appointment for you.

Non-Exotic Echocardiogram Form

NON-EXOTIC ECHOCARDIOGRAM FORM

Has the patient had a previous ultrasound or echocardiogram with Paw Prints?

Yes

If this patient might require sedation please list sedation recommendations here

What was the date of previous ultrasound or echocardiogram?

Patient ID Number

CLINIC DETAILS

All fields marked with a red asterisk * are required

Name of Clinic

Address

City

Province

Postal Code

Phone

Referring Veterinarian - First Name

Last Name

PATIENT DETAILS

All fields marked with a red asterisk * are required

First Name

Last Name

Species

Birthdate

Gender

Male

Female

Breed

Weight (kg)

Spayed / Neutered

Yes

CLIENT CONTACT INFO

(Optional)

Client First Name

Client Phone Number

APPOINTMENT DETAILS

Date

Time

Which studies will you be requesting today for this patient?

This ensures we will look for additional form submissions

Abdominal ultrasound

Echocardiogram

Thoracic ultrasound (chest)

Exotic ultrasound

Thyroid ultrasound

Pregnancy ultrasound

Free X-rays with echocardiogram and ECG

X-ray interpretation with echocardiogram ($77)

Yes

X-ray interpretation alone ($120)

Yes

Urgent report ($70)

Yes

Diagnostic ECG with ultrasound ($120)

Yes

Diagnostic ECG alone ($170)

Yes

STUDY INDICATION

Is there a non-IDEXX report from a previous study available for comparison?

Yes

If yes, please attach a PDF of the report with the other files for today's case

Please select the indications or clinical signs that prompted this study.

Please describe the other/not listed clinical signs. (max 250 chars)

Please select the chronicity of the heart murmur.

new

chronic

Please select any known or suspected triggers for the syncope/ collapse.

coughing

exercise/activity

other

Please describe the other/not listed triggers. (max 250 chars)

HISTORY

Please summarize pertinent history and/or elaborate on the clinical signs and study indications. (max 500 chars)

Questions about recent diagnostic tests and medications will appear later.

Was the patient sedated for any part of today's study?

Yes

Please select one option.

patient sedated for physical exam

patient sedated for diagnostic tests

patient sedated for both PE and diagnostics

Please list the sedation drugs administered

Currently the patient's appetite is reported to be

increased

decreased

stable

PHYSICAL EXAM

Temperature

Respiratory rate

Enter "panting", if applicable.

Pulse quality

Heart rate

Mucous membranes

Heart murmur

Yes

Heart murmur grade

Point of maximal intensity

left apical

right apical

left basilar

right basilar

left parasternal

right parasternal

heard loudly in all parts of the chest

Timing

systolic

diastolic

continuous

Cardiac rhythm

regular

irregular

Please describe the irregular rhythm.

Which of the following best describes the patient's attitude/demeanor?

bright

quiet

dull/depressed/lethargic

obtunded

comatose

anxious

aggressive

Body condition score

1 is the most thin and 9 is the most overweight, with 4-5 representing ideal conditioning

Any recent changes in body condition?

stable

recent weight gain

recent weight loss

recent muscle wasting

Please describe any additional relevant physical exam findings (max 500 chars)

DIAGNOSTICS

Systolic Blood Pressure result

Total T4 result

ProBNP result

Creatinine result

Heartworm test result

Completed diagnostics (max 500 chars)

Please summarize results of any other completed diagnostics. Write "none" if N/A.

Pending diagnostics (max 250 chars)

Please list any pending diagnostics. Leave blank if N/A.

Planned diagnostics (max 250 chars)

Please list any planned diagnostics not yet in progress or performed. Leave blank if N/A.

TREATMENT

Please describe any relevant prior treatments the patient received for the current clinical signs. (max 1000 chars)

Please list patient's current cardiac medications. (max 500 chars)

Include drug name, dosage, administration route, and frequency.

Please describe the patient's response to these cardiac medications, if any. (max 500 chars)

Please list any other medications the patient is taking, including supplements.Include drug name, dosage, administration route, and frequency, if possible. (max 500 chars)

Include drug name, dosage, administration route, and frequency, if possible.

OTHER

Do you need comments on anesthesia for a procedure planned in the short-term future?

Yes

Please list the planned anesthetic procedure

Is there any additional medically pertinent information to share

Yes

Please provide the medically pertinent information or case impressions (max 250 chars)

Are there any specific clinical questions or concerns you would like addressed in this report? (max 250 chars)

Do you have files to attach?

Yes

Maximum 10 files up to 10MB each.

Drop a file here or click to upload

Maximum 10 files up to 10MB each.
**This form only accepts .dcm, .dicom, .pdf, .jpg or .zip files**