Coughing/Sneezing Questionnaire

Is there discharge in your pet's sneezes, and if so- what color? *

Does your pet's behavior resemble allergies? *

Yes

No

Don't Know

Does your pet cough after exercise? *

Yes

No

Is there blood coming from the nostrils? *

Yes

No

Don't Know

When your pet coughs, do they Gag, Spit up, or Vomit? *

Pet Name: *

Have there been any changes to your pets routine? *

Yes

No

Does your pet sound like it is reverse sneezing? *

Yes

No

Don't Know

Phone *

Is your pet up to date on vaccines, specifically Bordetella? *

Yes

No

Don't know

Has your pet recently boarded? *

Yes

No

When do you notice it the most (AM/PM, etc?) *

Appointment date and time *

If yes, what type and when was it last given? *

Is your pet sneezing? If so, how frequently? *

Your Name: *

Was your pet recently in a shelter? *

Yes

No

If yes, what medication currently prescribed and how often is it given?

Could your pet have gotten into anything? (household detergents, etc.?) *

If any of the above, what does it look like? (White Foam, Mucous, Bile, Etc.?) *

Has your pet been to a dog park or a groomer? *

Yes

No

When did the cough start? *

Is your pet coughing? *

If yes, what does the cough sound like? (Deep, honking, harsh, dry, etc.?) *

Is your pet also coughing and/or wheezing while sneezing? *

Does your pet have trouble breathing between coughing fits? *

Yes

No

Has your pet been diagnosed with chf, bronchitis, pneumonia, etc.? *

Yes

No

Is your pet on heartworm medication? *

Yes

No

Don't know