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It requests patient identification details, current medications and supplements with dose, quantity, frequency, and refill needs, plus owner assessments of attitude, energy, exercise ability, appetite, sleep comfort, cough or choking severity and frequency, breathing difficulty severity, and any episodes of collapse or fainting with timing and description. It also captures changes since the last visit and includes veterinarian guidance on key clinical observations.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/cardiac-patient-history-form-complete-and-bring-to-examination/307729/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/cardiac-patient-history-form-complete-and-bring-to-examination/307729.png","ImageObject",442,249,{"name":88,"@type":89},"Berry Peter","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What medication details does the form ask the owner to provide?","Question",{"text":109,"@type":110},"It asks for medications/supplements, dose (mg), quantity, and frequency per day. It also asks whether a refill is needed and uses checkboxes for tracking dosing patterns.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form evaluate changes since the last visit?",{"text":114,"@type":110},"For multiple sections (attitude/energy, appetite, sleep, cough, breathing, and collapse), it includes options to mark Better, Worse, or No Change and asks for a time course of change in weeks or months.",{"name":116,"@type":107,"acceptedAnswer":117},"What guidance does the veterinarian key provide for dogs with heart failure?",{"text":118,"@type":110},"It notes that dogs may show decreased energy and exercise ability, altered interactions, decreased appetite, restless or uncomfortable sleep, cough that can wake at night, and breathing abnormalities. It also highlights syncope and recommends further diagnostics such as radiographs, electrocardiogram (with or without Holter), and echocardiogram.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307729,1790634094,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Canine Patient History Form  \nDate:    \nPatient:    \nPatient Label:  \n\n| Please ComPlete tHis Form & bring to examination along witH your mediCations & resPiratory log |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Medications/ supplements1: | Dose (mg): | Quantity: | Frequency/day: |  |  |  |  | Refill needed? |  |\n|  |  |  | o 1 | o 2 | o 3 | o 4 | o occasionally | o yes | o no |\n|  |  |  | o 1 | o 2 | o 3 | o 4 | o occasionally | o yes | o no |\n|  |  |  | o 1 | o 2 | o 3 | o 4 | o occasionally | o yes | o no |\n|  |  |  | o 1 | o 2 | o 3 | o 4 | o occasionally | o yes | o no |\n|  |  |  | o 1 o 2 o 3 o 4 o occasionally |  |  |  |  | oyes o no |  |\n\n\n|  How is your pet’s overall attitude, energy level, exercise ability?2 1 = very low 5= normal o 1 o 2 o 3 o 4 o 5 |  |\n| --- | --- |\n| Has this changed from last visit? o Better o Worse o No Change Time course of change: | o weeks o months |\n\n\n|  How is your pet’s appetite?3 1 = very low 5= normal o 1 o 2 o 3 o 4 o 5 |  |\n| --- | --- |\n| Has this changed from last visit? o Better o Worse o No Change Time course of change: | o weeks o months |\n\n|  Does your pet sleep comfortably?4 o Yes o No o Don’t know If no, then please describe:   |  |\n| --- | --- |\n| Has this changed from last visit? o Better o Worse o No Change Time course of change: | o weeks o months |\n\n\n|  Does your pet cough, gag, retch, or choke?5 o Yes o No How severe is it? 1= very mild 5= severe o 1 o 2 o 3 o 4 o 5 |\n| --- |\n| How often? o 1/week o 1/day o Several times a day o All the time When? o mostly at night o mostly with excitement o any time |\n| Has this changed from last visit? o Better o Worse o No Change Time course of change:   o weeks o months |\n\n\n|  Does your pet have trouble breathing?6 oYes o No |\n| --- |\n| How severe is the breathing problem? 1= mild difficulty 5= severe difficulty o 1 o 2 o 3 o 4 o 5 |\n| Has this changed from last visit? o Better o Worse o No Change Time course of change:   o weeks o months |\n\n\n|  Has your pet collapsed or fainted?7 o Yes o No How frequent are the episodes? o 1/month o 1/week o 1/day oSeveral times a day |\n| --- |\n| When did the collapsing start? |\n| Please describe what it looks like:  \u003Cbr>|\n| Has this changed from last visit? o Better o Worse o No Change Time course of change: o weeks o months |\n\n\n| Do you have other concerns?   |\n| --- |\n|  |\n\nCardiac Patient History Form (page 2)  \nVeterinarian Key For Patient History Form  \n1. Verify that the client is administering the intended medications, doses, and frequencies by comparing this form to your medical record.  \n2. Dogs with heart failure often have decreased energy, decreased exercise ability, or altered interactions with the client. Osteoarthritis or other systemic diseases may also cause these abnormalities.  \n3. Dogs may have a decreased appetite due to heart failure, medications, or other systemic diseases.  \n4. Dogs with heart failure may be uncomfortable or restless when they sleep, and may have to sleep in a sternal position. Cough may wake them up in the night.  \n5. Coughing, retching, gagging or choking may be present in dogs with heart failure, and further evaluation with radiographs is needed.  \n6. Tachypnea (resting respiratory rate > 35 breaths/minute) and dyspnea are common clinical abnormalities in dogs with heart failure, and further evaluation with thoracic radiographs is indicated. Review of the owner’s respiratory log of their dog’s at home resting respiratory rate helps assess the likelihood of current heart failure.  \n7. Syncope may be present in dogs with heart failure, pulmonary hypertension, or an arrhythmia. Further diagnostic tests including an electrocardiogram (+/- holter monitor) and an echocardiogram are indicated  \nVCA 020 TR","cbCaij4rDWGJDu7T","https://ap.wps.com/l/cbCaij4rDWGJDu7T","pdf",156760,"English","# Medications and Supplements\n## Attitude, Energy, and Exercise Ability\n## Appetite\n## Sleep Comfort\n## Coughing and Choking\n## Breathing Trouble\n## Collapse or Fainting\n## Other Concerns\n# Veterinarian Key (Patient History Guidance)","[{\"question\":\"What medication details does the form ask the owner to provide?\",\"answer\":\"It asks for medications/supplements, dose (mg), quantity, and frequency per day. It also asks whether a refill is needed and uses checkboxes for tracking dosing patterns.\"},{\"question\":\"How does the form evaluate changes since the last visit?\",\"answer\":\"For multiple sections (attitude/energy, appetite, sleep, cough, breathing, and collapse), it includes options to mark Better, Worse, or No Change and asks for a time course of change in weeks or months.\"},{\"question\":\"What guidance does the veterinarian key provide for dogs with heart failure?\",\"answer\":\"It notes that dogs may show decreased energy and exercise ability, altered interactions, decreased appetite, restless or uncomfortable sleep, cough that can wake at night, and breathing abnormalities. It also highlights syncope and recommends further diagnostics such as radiographs, electrocardiogram (with or without Holter), and echocardiogram.\"}]","Cardiac Patient History Form - Complete and bring to examination | PDF",1789853884]