| Has your cat been coughing?: |
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| If so, when did it first start?: |
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| Estimate number of times a day your cat is seen coughing?: |
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| Is the coughing sometimes associated with production of a hairball?: |
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| Is your cat sneezing?: |
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| Has there been any vomiting?: |
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| Have you noticed your cat breathing hard at rest?: |
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| Is there now, or has there been any discharge from the nose?: |
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| Please describe discharge if any.: |
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| Are there other cats in the household?: |
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| Are any other cats affected?: |
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| Does your cat seem to have times when it is difficult to breath?: |
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| Please list all medications and frequency for the past month: |
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| Has anyone given your cat Tylenol/Acetaminophen?: |
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| Is your cat's appetite?: |
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| Diet: including treats and supplements?: |
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| Is your cat's energy level?: |
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| Does your cat seem to have lost weight?: |
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| Does anyone in the household smoke?: |
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| Type of cat litter used?: |
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| Is your cat's litter dusty?: |
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| Is your cat: |
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| Are you interested in holistic alternatives?: |
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