Pet Owner History Form

Pet Owner History Form
General Information
Your pet's name *
Your name*

First NameLast Name
Your email*

Confirmation Emailexample@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?*

YesNo
Current symptoms
Is your pet coughing?*

YesNo
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)*

AnytimeFirst thing in the morningIn the middle of the nightAfter getting up from a laying positionAfter drinking or eatingWith excitement/exercise/stressAt restOther
How does the cough sound like? (Check all that apply)*

HackingHonkingSoftWheezyWet soundingEnds with a retch/gagOther
Is your pet having any increased respiratory effort/laboured breathing?*

YesNo
When did the increased respiratory effort first start?*
When do you generally notice increased respiratory effort?*

At restWith exercise/ excitementAll the time (at rest and with exercise/excitement)
Does the tongue of your pet ever become blue/purple?*

YesNo
Does your pet's breathing appear abnormally rapid?*

YesNoI 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?*

YesNo
How many episodes have you witnessed?*
What does usually happen just prior to the episode(s)? (Check all that apply)*

Nothing in particularSleepingExcitementExerciseCoughingVomiting or defecatingOther
During the episode(s), what did you notice about your pet? (Check all that apply)*

UnconsciousConsciousLimp / weakStiff / RigidExtension of the neck (arched toward the back)TremblingPaddling / moving legsDroolingUrinationDefecationPale gumsBlue/purple gumsOther
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?*

NormalDecreasedIncreased
How is your pet's weight?*

NormalDecreasedIncreased
How is your pet's water intake?*

NormalDecreasedIncreased
How is your pet's urination?*

NormalDecreasedIncreased
How is your pet's exercise capacity?*

NormalDecreasedIncreased
Have you noticed any vomiting?*

NoneRareWeeklyDaily
Have you noticed any diarrhea?*

NoneRareWeeklyDaily
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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Please verify that you are human*
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Pet Owner History Form

General Information

Current symptoms