Chronic Regurgitation Questionnaire Posted on September 28, 2022September 28, 2022 by Cheshire "*" indicates required fields Brachycephalic Dogs & Dogs with Chronic Regurgitation QuestionnaireOwner's Name* First Last Patient's Name* Owner's Email*For a copy of this form. Does your pet have signs of regurgitation or reflux?*Check all that apply Burping Spitting up (water or food) Hard swallows Gagging Hacking Appearance of nausea Explain symptoms and how often they are demonstratedDoes your pet receive medications to prevent/treat reflux/regurgitation? Some of these medications could include: Famotidine (Pepcid), Omeprazole (Prilosec), Metoclopramide (Reglan)* Yes No Please list medicationsMedication 1Medication 2Medication 3 Add RemoveHow would you describe your pet’s breathing at home?* Mild: quiet breathing Moderate: quiet at rest, loud when excited Severe: loud, notable when sleeping, periods of labored breathing, blue/purple coloring of their tongue or gums Explain symptoms and how often they are demonstrated:Has your pet undergone anesthesia in the past?* Yes No If yes, were there any complications? Has your pet had surgery to correct brachycephalic obstructive airway syndrome (BOAS)?* Yes No If yes, please list the location for record retrieval. Has your pet had pneumonia?* Yes No If so, when was the last diagnosed bout? Have chest radiographs of your pet been performed in the past 6 months?* Yes No If yes, where and for what reason? Has your pet been hospitalized for any GI issues or breathing abnormalities?* Yes No If yes, when and at what hospital? Today's Date:* Month Day Year CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.