Leawood-plaza - Canine Health Questionnaire

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Canine Health Questionnaire

One of the challenging aspects of veterinary medicine is evaluating the health of patients who cannot talk to us. Remembering that pets age at a rate up to seven times faster than our own, makes this challenge even more important. As pet health care professionals, we depend greatly on the information provided to us by pet owners and family members. We would like to ask for your assistance.

In an effort to provide your pet with the best health care, we ask that you take just a few moments to answer the following questions. Making health care decisions with respect to age and lifestyle allows us to tailor our treatment and advice more effectively for every patient.

We thank you (and your pet thanks you) for your assistance toward this effort!
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* This field is required.
Yes
No
Is your dog ever outside unsupervised?
Yes
No
Does your dog ever come in contact with other pets or their environments?
Yes
No
Is wildlife in your area, including mice, squirrels, birds, possums, raccoons or skunks?
Yes
No
Do you ever take your dog to dog shows?
3
Your Email
example@example.com
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* This field is required.
Yes
No
Do you ever take your dog to the pet store?
Yes
No
Do you take your dog to a grooming or boarding facility?
Yes
No
Do you hunt with your dog?
Yes
No
Does your dog travel with you?
5
* This field is required.
Yes
No
Do you ever handle unvaccinated dogs?
Yes
No
Has your dog had a heartworm test in the last year?
Yes
No
Has your dog had a stool examination for intestinal parasites in the last year?
6
Yes
No
Is your dog currently on heartworm preventative?
If yes, please list
Yes
No
Is you dog currently on any medication for fleas?
If yes, please list
7
* This field is required.
Yes
No
Have you found ticks on your dog in the last year?
Yes
No
Has your dog ever had any adverse reaction to vaccinations?
Yes
No
Does you dog sleep with you or your children?
What diet do you feed your dog?
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* This field is required.
Do you give any supplements (vitamins, herbal/holistic medications etc) to your pet? If yes, please list.
Is your dog currently on any medications, if so what is the dosage you are giving and how often?
Pleasant - Not bad
Unpleasant - Really Bad (needs mouthwash!)
Which best describes your dog’s breath?
Not a big water drinker
Normal
Occasionally drinks a lot
Always drinks a lot
Which best describes your dog’s water consumption
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Please select any conditions that apply to your dog* This field is required.
Vomiting
Diarrhea
Constipation
Incontinence
Increased thirst
Frequent urination
Difficulty jumping
Limping
Difficulty with stairs
Seizures
Skin growths
Itchy skin
Vision problems
Hearing problems
Behavioral changes
Coughing
Other
None
10
If Other, please specify
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* This field is required.
Owners Name
Pet’s Name
Date
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Do you already have an appointment scheduled with us?* This field is required.
YESNO
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What date and time is your appointment? *Please note that the last available appointment on Saturday's is 11:45 AM
Should be Empty: