Pet Owner History Form
General Information
Your pet's name
*
Your name
*
First Name
Last Name
Your email
*
Confirmation Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
At which veterinary clinic will the evaluation take place?
*
What is your pet's diet? (Brand and specific name of the diet)
*
Is your pet receiving heartworm prevention?
*
Yes
No
Current symptoms
Is your pet coughing?
*
Yes
No
When did the cough first start?
*
How frequent is the cough?
*
Rare (a few times monthly)
Intermittent (several times weekly)
Daily (occasional)
Daily (frequently)
Other
When does the cough generally occur? (Check all that apply)
*
Anytime
First thing in the morning
In the middle of the night
After getting up from a laying position
After drinking or eating
With excitement/exercise/stress
At rest
Other
How does the cough sound like? (Check all that apply)
*
Hacking
Honking
Soft
Wheezy
Wet sounding
Ends with a retch/gag
Other
Is your pet having any increased respiratory effort/laboured breathing?
*
Yes
No
When did the increased respiratory effort first start?
*
When do you generally notice increased respiratory effort?
*
At rest
With exercise/ excitement
All the time (at rest and with exercise/excitement)
Does the tongue of your pet ever become blue/purple?
*
Yes
No
Does your pet's breathing appear abnormally rapid?
*
Yes
No
I am not sure
What is your pet's average respiratory rate when sleeping? (Please find information on how to acquire a respiratory rate under the 'For pet owners' section)
Is your pet having any collapsing or seizure-like episodes?
*
Yes
No
How many episodes have you witnessed?
*
What does usually happen just prior to the episode(s)? (Check all that apply)
*
Nothing in particular
Sleeping
Excitement
Exercise
Coughing
Vomiting or defecating
Other
During the episode(s), what did you notice about your pet? (Check all that apply)
*
Unconscious
Conscious
Limp / weak
Stiff / Rigid
Extension of the neck (arched toward the back)
Trembling
Paddling / moving legs
Drooling
Urination
Defecation
Pale gums
Blue/purple gums
Other
How long did the episode(s) last?
*
How long did it take for your pet to return completely to normal?
*
How is your pet's appetite?
*
Normal
Decreased
Increased
How is your pet's weight?
*
Normal
Decreased
Increased
How is your pet's water intake?
*
Normal
Decreased
Increased
How is your pet's urination?
*
Normal
Decreased
Increased
How is your pet's exercise capacity?
*
Normal
Decreased
Increased
Have you noticed any vomiting?
*
None
Rare
Weekly
Daily
Have you noticed any diarrhea?
*
None
Rare
Weekly
Daily
If your pet is currently taking any medications, please list the name, strength and dosage.
List any other significant health problems that your pet has had in the past:
Is there anything else you would like to share with me? (such as other signs or changes that you have noticed)
You may upload short videos of specific symptoms you have noticed (such as coughing, collapsing or seizure-like episodes, etc.)
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