Client Name: Patient Name:Address: Species: Breed: Sex::MaleFemaleAge: What is your pet’s current sleeping respiratory rate? What clinical signs are you observing? (ex: coughing/ gagging, wheezing or other changes in breathing, fainting, fatigue or exercise intolerance, etc.) If yes, would your like written prescriptions or pills to take home today? Yes NoWhat tests has your veterinarian done since these signs have manifested? (ex: xrays, bloodwork, or EKG)Is your pet eating and drinking normally? Are urinations and bowel movements normal? Please list all medications your pet is taking, including the strength, dose, how often they take it, and the time it was last administered (ex: furosemide 12.5mg – 1 tablet two times per day, last given at 8AM today)Do you feel there has been a change in your pet’s symptoms since your last visit? Do you need a refill on any cardiac medications? Yes NoDate of last round of vaccinations:Date of last heartworm test and result:Type of heartworm prevention given, and how often it is given:Any known allergies to food or medication?What foods/treats do you feed your pet?For cats only:Has your pet been tested for feline leuk. or feline aids? Yes NoWas the result positive or negative? Pos NegDoes your pet go outside? Yes NoIf your pet does go outside- how long does it spend outside?