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Brachycephalic and Airway History Form

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Brachycephalic and Airway History Form

Thank you for trusting us with your pet’s care! If your pet is any of the following breeds, we ask that you fill out and submit this form prior to their visit:

Bulldog (French, American, or English), boxer, pug, boston terrier, shih tzu, pekingese, bullmastiff, japanese chin, cavalier king charles spaniel, brussels griffon, lhasa apso, shar pei, staffordshire bull terrier, tibetan spaniel, dogue de bordeaux, labrador retriever, golden retriever, siberian husky, and newfoundland.

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Client Name

Patient Information

Does your pet experience anxiety around vet visits or novel situations?
Does your pet typically require calming/sedation medications to be seen at the vet?
Does your pet snore?
Can you hear them breathing from the next room over?
Does your pet struggle to breathe while sleeping?
Does your pet wake up suddenly in distress?
Do they have limitations on play or walking activity?
Does your pet experience fainting or collapse episodes?
Has your pet had any upper airway surgery previously?
Does your pet experience vomiting? (Vomiting is an active process involving abdominal contractions, retching, and forceful expulsion of stomach contents.)
Does your pet experience regurgitation? (Regurgitation, on the other hand, is a passive process where esophageal contents, often undigested food/water/saliva, are brought back up without much effort or retching.)
Does your pet experience diarrhea or abnormal stool?
Does your pet have difficulty eating food?