Brachycephalic Breed Questionnaire
I believe in the importance of pet health care and wellness, particularly for brachycephalic (flat-faced) breeds.Your day to day observations are of great importance when it comes to your pet's overall wellness. Please complete the following questionnaire.
Primary Contact
Please enter information for the primary contact person for this patient (must be over 18 years of age).Â
Name
*
Mr.
Mrs.
Miss.
Ms.
Dr
Prefix
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Post Code
Email
*
Phone (Mobile preferred)
*
Secondary Contact if applicable (Name & Phone number)
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Animal Details
Please complete the following for your pet.
Animal name
*
Animal breed
*
Gender
*
Male
Female
Unsure
Is your pet desexed?
*
Yes
No
Unsure
Animal Date of Birth or Age (years, months)
*
Estimated weight (if known)
Is your pet insured?
*
Yes
No
Unsure
Insurance policy number (if known)
Where did you get your dog from?
Australian National Kennel Council (ANKC) Breeder
Master Dog Breeders Association (MDBA) Breeder
Family or friend
Online
Rescue or Pound
Other type of breeder
Other
Please list your regular vet clinic or hospital:
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Medical History
Please describe any current medical concerns you have for your dog:
Please list any current medications your pet receives:
Has your dog had any airway surgery in the past?
*
Yes
No
Unsure
If YES to previous airway surgery, do you know what part of the airway? (Tick all that apply)
Nares
Soft Palate
Tonsils
Saccules
Unsure
Not applicable / Never had airway surgery
Has your dog undergone any other procedures involving an anaesthetic in the past (including desexing)?
*
Yes
No
Unsure
Please provide further details of previous surgical procedures (including age and outcome of surgery):
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Diet, Appetite & Gastrointestinal Signs
Please select the types of foods your dog currently receives in their diet? (Select all that apply)
*
Dry dog biscuits / kibble
Canned dog food
Prime100 rolls
Left overs
BARF
Pet meat
Raw food
Vegetables
Dental chews
Supplements (eg. vitamins or minerals)
Other
Other:
How often do you feed your dog?
Once daily
Twice daily
Three times daily
Food is out all day
Other
How would you describe your dog's appetite in the MORNING?
Poor
1
2
3
4
Ravenous
5
1 is Poor, 5 is Ravenous
Has your dog ever experienced the following signs:
Vomiting
Diarrhoea
Burping or belching
Flatulence (Farting)
Regurgitation or Reflux
NONE of the above
Other
Does your dog ever regurgitate or vomit their food or water?
*
Yes - Daily
Yes - 1-3 times per week
Yes - 1-3 times per fortnight
Yes - 1-3 times per month
Not sure
Never
If yes, describe what is brought up:
If yes, please enter details of any signs that concern you:
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Exercise & Breathing
How many times per week, on average, do you exercise your dog?
None
Once per week
Twice per week
3 times per week
4 times per week
5+ times per week
Please describe the type of exercise (walking, swimming, running, ball chasing etc):
How many minutes do you exercise your pet on average per session?
Does your dog breathe loudly during PHYSICAL EXERCISE such as walking, running, ball chasing (e.g. snorting, grunting, heavy breathing)?
*
Yes - Often
Yes - Occasionally
Not sure
Never
Does your dog breathe loudly while AWAKE at REST (e.g. snorting, grunting, heavy breathing)?
*
Yes - Often
Yes - Occasionally
Not sure
Never
Does your dog regurgitate or vomit foam/froth/phlegm during exercise?
*
Yes - Most times
Yes - Occasionally
Not sure
Never
Has your dog ever fainted or collapsed during exercise?
*
Yes
Never
Not sure
** OPTIONAL ** Exercise Test
On a 25 (or 77 fahrenheit) degree day, running your dog around down the park off lead for up to 30 minutes, compare their breathing to a same aged normal length of nose dog, such as a Labrador.
Do they puff and pant more quickly and/or with more effort than the normal nose dog with the same degree of exercise?
Yes
No
Unsure
Do they take longer to close their mouth and recover than the normal nose dog with the same degree of exercise?
Yes
No
Unsure
How long does your dog take to relax back to normal breathing (closed mouth) after exercise?
Under 5 minutes
5-10 minutes
10-15 minutes
15-20 minutes
20-25 minutes
Over 25 minutes
Unsure
Describe any other concerns or comments about your dog's exercise tolerance:
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Sleeping Habits
Does your dog SNORE or breathe loudly while SLEEPING?
Yes - Often
Yes - Occasionally
Never
Not sure
During sleep, has your dog ever: (tick all that apply)
Fallen asleep in a sitting position
Fallen asleep with a toy in their mouth
Woken to reposition themselves
Slept with their chin elevated (e.g. resting on a toy, furniture or on a cushion)
NONE of the above
Do you have any other comments about your pet's breathing or sleeping habits?
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Skin & Tail
Has your dog had skin problems (such as allergies) in the past?
Yes
No
Unsure
If yes, please tick which of the following you have tried to manage their skin problems (tick all that apply):
Shampoo/Conditioner
Diet Change
Antihistamines
Antibiotics
Apoquel tablets
Cytopoint injection
Steroid tablets
Other
Does your dog scoot or rub its bottom along the ground?
Yes
No
Unsure
Does your dog have a short, coiled tail?
Yes
No
Unsure
Do you clean your dog's tail pocket?
Yes
No
Unsure
Do you clean the face folds of your dog?
Yes
No
Unsure
If you clean the tail pocket and/or face folds, please describe how frequently do you do this and what with?
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Please tick what you are interested in finding out more about (you can select more than one option):
Airway (BOAS) Surgery or Assessment
Screw Tail Surgery or Assessment
Eye Problems
Skin Fold Reduction Surgery or Assessment
Desexing
Ear Problems
Other
Where did you hear about me?
Please Select
BAHA - Brachycephalic Australia Health Awareness FB group
Recommended by a Friend
Recommended by my Vet
Facebook
Instagram
Google
Other
If you were referred from a friend, please leave their name so I can thank them.
Please list any other concerns or questions you have about your dog:
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