Today's Date:

Owner's Name [*]

Email [*]

Phone [*]

Pet's Name [*]

NUTRITION

What dog food do you give your pet?

How much do you feed?

Any medications, supplements, vitamins or other items?

PARASITES

Does your pet receive heartworm prevention year-round? Y / N?

If yes, what brand?

Number of doses over the last 12 months

What do you use for flea and or tick control/prevention?

Have you seen any fleas or ticks on your pet?

Does your dog have a Microchip?
NONE SELECTED YES NO I don't know

MEDICAL

Does your dog vomit more than 1 time per week? [*]
NONE SELECTED YES NO

Has your dog had any abnormal bowel movements? (should be firm, formed, mucus free) [*]
NONE SELECTED YES NO

Has your dog had any coughing or sneezing? [*]
NONE SELECTED YES NO

Has your dog's activity level changed (acts tired, inactive)? [*]
NONE SELECTED YES NO

Does your dog scratch, lick or chew any part of its body? [*]
NONE SELECTED YES NO

Have you noticed any lumps or bumps on your dog? [*]
NONE SELECTED YES NO

Does your dog have cloudy eyes or discharge? [*]
NONE SELECTED YES NO

Have you noticed any discharge or odor from your dog's ears? [*]
NONE SELECTED YES NO

Has your dog's appetite changed in the last year? [*]
NONE SELECTED YES NO

Does your dog drink more than usual? [*]
NONE SELECTED YES NO

Does your dog urinate more than usual? [*]
NONE SELECTED YES NO

Does your dog have difficulty climbing stairs, limp, or lag behind on walks? [*]
NONE SELECTED YES NO

Does your dog display inappropriate behavior (discipline)? [*]
NONE SELECTED YES NO

Does your dog display aggressive behavior (bite or growl)? [*]
NONE SELECTED YES NO

Do you brush your pet’s teeth or give dental chews? (brand) [*]
NONE SELECTED YES NO

Does your dog show signs of motion sickness (gets sick when riding in the car)? [*]
NONE SELECTED YES NO

LIFESTYLE

Are there other animals in house? [*]
NONE SELECTED YES NO

Number of Dogs:

Number of Cats:

Other:

Regular exercise? (select all that apply):
Free in yard
Go on walks
Dog parks
Wooded/water areas

Have you boarded your pet for the day or overnight? [*]
NONE SELECTED YES NO

Do you take your pet for grooming ? [*]
NONE SELECTED YES NO

Has your pet ever had a dental cleaning or procedure? [*]
NONE SELECTED YES NO

Any other concerns you may have about your pet?