EXAM Respiratory EXAM Respiratory This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:* Your name:* When did your pet start experiencing symptoms?*What exactly are you seeing at home?*If your pet is sneezing, approximate how many times per day: If your pet is coughing, approximate how many times per day: If your pet is coughing, is it:* a wet cough a dry cough my pet is not coughing Does your pet have nasal discharge? If so, please describe the colour, and if there is any blood present: Stool Quality Score*Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.12345Describe the diarrhea, if any. Are there large puddles, small droplets, does there appear to be blood or mucous in it?Is your pet vomiting? If so, how many times per day:If your pet is vomiting, please describe the appearance (colour, size, if blood is present, etc.):Have you noticed any changes in your pet's personality or behaviours?* yes no Describe your pet's energy level. Has it increased/decreased?*What kind of food are you feeding your pet?*Is your pet fed a grain-free diet? Yes No How long has your pet been on this diet?*What table scraps/homemade cooking or treats does your pet get?*In your opinion, is your pet drinking more frequently?* yes no unsure In your opinion, is your pet urinating more frequently?* yes no unsure Have there been any recent accidents in the house?* yes no Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?* yes no Does your pet hunt?* yes no Does your pet roam freely outdoors?* yes no Are your pet's vaccinations up to date?* yes no unsure Is your pet on flea/tick prevention currently?* yes no Have you seen any fleas/ticks on your pet in the last year?* yes no Which flea/tick product do you use for your pet? Do you still have any remaining? When was your pet last dewormed?* Have you brought a stool sample today?* yes no Has your pet bitten any person in the last 10 days which broke the skin?* Yes No Please list any questions/problems/concerns for Dr. Jinni that you would like addressed: Δ