Brachycephalic Breed Questionnaire Carlson

We thank you for helping us give you the best service possible by completing this
form within 24 hours of receiving.

Your First and Last Name (On Account) *

Phone Number To Contact You During Appointment *

Please enter a valid phone number.

Date *

Date

Pet Name *

Pet Sex *

Male Neutered Male Female Spayed Female

Birth Date *

Breed *

Does your pet have increased noise (breathe loudly) during normal breathing? *

Yes No

Does your pet have labored breathing? Is it mild, moderate or severe? What triggers labored breathing? *

If not applicable, please write none in the box

Does your pet have difficulties getting comfortable? *

Yes No

In what position does your pet sleep most commonly? *

Is there any coughing? If so, how often? Is it dry or productive (mucous)? *

If not applicable, please write none in the box

Is there any choking or gagging? If so, how frequently? *

If not applicable, please write none in the box

Is there any vomiting? If so, how frequently? *

If not applicable, please write none in the box

Does your pet ever collapse? If so, how frequently? *

If not applicable, please write none in the box

When did you first notice respiratory signs? *

If not applicable, please write none in the box

Is your pet overweight or has a doctor ever said that he/she is overweight? *

If not applicable, please write none in the box

Do you think that your pet is an ideal weight? *

Yes No

Have you noticed any respiratory effort during inhalation at rest? If so, please describe. *

If not applicable, please write none in the box

Have you noticed any respiratory effort during exhalation at rest? If so, please describe *

If not applicable, please write none in the box

Do your pet’s gums ever turn blue (cyanotic)? If so, when does this occur and how often? *

If not applicable, please write none in the box

Does respiratory effort or panting worsen with exercise? If so, please describe. *

If not applicable, please write none in the box

Does your pet reverse sneeze? If so, how frequently? *

If not applicable, please write none in the box

Do you hear any wheezing during breathing? *

Yes No

Approximately how long (in minutes) can your dog walk in the fall? *

Approximately how many minutes does it take your dog to recover from a walk in the fall? *

Approximately how long (in minutes) can your dog walk in the winter? *

Approximately how many minutes does it take your dog to recover from a walk in the winter? *

Approximately how long (in minutes) can your dog walk in the spring? *

Approximately how many minutes does it take your dog to recover from a walk in the spring? *

Approximately how long (in minutes) can your dog walk in the summer? *

Approximately how many minutes does it take your dog to recover from a walk in the summer? *

Do you feel that there is any difference in breathing associated with the environmental temperature? If so, what temperature appeared problematic? *

If not applicable, please write none in the box

Do you feel that there is any difference in exercise tolerance associated with the environmental temperature? If so, what temperature appeared problematic? *

If not applicable, please write none in the box

Do you feel that there is any difference in recovery from exercise associated with the environmental temperature? If so, what temperature appeared problematic? *

If not applicable, please write none in the box

Can your dog play with other dogs without tiring easily? *

Yes No

Can your dog keep up with other dogs while playing? *

Yes No

Does your dog have any difficulty eating? Please describe *

If not applicable, please write none in the box

Is your dog's appetite normal? *

Yes No

Is there any choking? If so, how frequently? *

If not applicable, please write none in the box

Is there any vomiting? If so, how frequently? *

If not applicable, please write none in the box

Is there any regurgitation? If so, how frequently? *

If not applicable, please write none in the box

Do you notice any increase in saliva? If so, how often? *

If not applicable, please write none in the box

Do you notice any reoccurring licking of lips? If so, how often? *

If not applicable, please write none in the box

Can your dog sleep while lying down? *

Yes No

Can your dog sleep while lying on its' side? *

Yes No

Does your dog have any bouts of choking during sleep? If so, how often? *

If not applicable, please write none in the box

Can your dog sleep with his/her mouth closed? *

Yes No

Does your dog sleep while sitting up? *

Yes No

Is your dog able to sleep? *

Yes No

Does your dog sleep with the chin elevated? *

Yes No

Do you notice any signs of sleep apnea? If so, how frequently? *

If not applicable, please write none in the box

Does your dog sleep with a toy in its mouth, keeping the mouth open? *

Yes No

What are the most restrictive problems for your dog? Please select the applicable problems below. *

Exercise Intolerance (inability to play with other dogs) Breathing Problems Problems Feeding Problems Sleeping

CANCELATION POLICY

While we do understand emergencies and other scheduling conflicts can happen and are sometimes unavoidable, we request a 24-hour notice to change or cancel an appointment. After two missed or canceled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.

Thank you for completing this questionnaire. If you have any questions please call us 708.383.3606

Brachycephalic Breed Questionnaire

Important Information

Patient Questionnaire

Exercise and Heat Tolerance

Feeding

Sleep

Welfare