Coughing Triage Form

Owner's Name:

Pet's Name:

Species:

Spayed or Neutered?YesNo

Age:

Best way to contact owner:

Primary Concerns

When did the coughing first start?

Has your pet behavior changed recently?

Is your pet having difficulty breathing? If yes, please describe:

What type/brand of food is your pet on?

Any recent changes in your pets diet or eating habits?

Has your pet be exposed to other animal?KennelsDaycarePlay groupsGrooming

Has your pet had any coughing issues in the past? If yes, how were they treated:

Is your pet currently on any medications and dosages?

Does your pet have any known allergies or chronic illnesses?

Is there anything else we should know about your pet?

Is your pet up to date on vaccines?

Has your pet had the bordetella or influenza vaccine in the past?