Has your cat been coughing? Y/N If so, when did it first start?___________ Estimate number of times a day cat is seen coughing_________________ Is the coughing sometimes associated with production of a hairball? ____ Is there also sneezing? Y/N / Not sure Vomiting? Y/N/Not sure Have you noticed him/her breathing hard at rest? Y/N/Not sure Is there or has there been discharge from the nose?____________________ Was it clear, or what did it look like? ____________________________ Are there other cats in the household? Y/N __________________________ Are any of the other cats affected? Y/N/Not sure____________________ Does he/she ever seem to have times when it is difficult to breath? Y, N Have you given your cat any medication or other treatment for this problem? ______In the last week? __________Month?________________ Has your cat been given any other medication for any reason in the last week? ____Month? ______If yes, what?___________________________ Has anyone given your cat Tylenol/acetaminophen ?___________________ Is your cat’s appetite: decreased, normal or increased?________________ Diet: including any treats or supplements:___________________________ Is your cat’s energy level: decreased or normal?______________________ Does he/she seem to have lost weight?______________________________ Has his/her energy level changed recently? _________________________ Does anyone in the household smoke? Type of cat litter used: (circle all that apply) fine granules, crystals, Clumping, pellets, other __________________Is it dusty?_______ Is your cat indoor only, indoor-outdoor or outdoor? Are you interested in holistic alternatives? Y/N
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