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Coughing and Sneezing Questionnaire
First Name
Last Name
E-mail
My pet has
sneezing
coughing
runny nose
runny eyes
When did you first notice these symptoms?
today
yesterday
more than two days ago
My pet is eating normally
Yes
No
My pet is drinking water
normal
more
less
My pet’s activity level is
normal
lethargic
hyperactive
Has your pet been boarded or been around other pets recently?
Yes
No
My pet is kept
indoors
outdoors
both
If you have other pets in the household are they showing any similar symptoms?
Yes
No
My pet coughs
only in the morning
after activity
at night
regularly
Does the cough sound
moist
dry
hacking
honky
My pet sneezes
several times in a row
many times daily
occasionally
The discharge from the eyes is
clear
brownish
green/yellow
The discharge from the nose
clear
green/yellow
bloody
Are there any recent changes in the pet’s environment such as a new pet, new household cleaners, new carpet, exposure to burning wood, cigarettes, etc.?
Yes
No
Has your pet ever been treated for these or similar symptoms before?
Yes
No
Is your pet on any medications?
Yes
No
Does your pet have any other symptoms not addressed on this form?
Yes
No
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