Canine Lifestyle Assessment Form

Canine Lifestyle Assessment Form
Pet Owner Name:
Name of Dog:
Breed:
Sex

FemaleFemale, SpayedMaleMale, Neutered
Date of Birth:

MonthDayYear
Date
Date of last preventive care visit:

MonthDayYear
Date
1. How many dogs live in your home?
2. How many cats?
3. Other pets in the household include:
4. Do you take your dog to any of the following (check all that apply):

Dog parksDoggie day careBoarding or grooming facilitiesPuppy schoolObedience trainingOrganized competitions
5. How many hours does your dog spend outside every day?
6. Do you travel with your dog?

YesNo
7. Do you take your dog hiking, hunting, camping or fishing?

YesNo
8. Do you observe wild animals or other wildlife in your neighborhood?

Feral CatsSquirrels, Chipmunks, Skunks or Small RodentsRaccoonsDeerWild TurkeysWild Canines (Coyotes, Foxes)Other
9. Do you or your dog visit homes where there are pets?

YesNo
10. Do other pets come to visit at your house?

YesNo
11. Does anyone with compromised immune systems live in or visit your home?

YesNo
12. Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?

YesNo
13. Which pets do you treat for fleas, ticks, internal parasites, or heartworms?

Dog(s)Cats
14. Please list all of the products, medications or supplements your dog is using:
Flea or tick control products
Heartworm Prevention
Pain medications (including prescriptions, aspirin or supplements)
Dental products (including chews)
Other
15. What kind of diet do you feed your dog?
16. Do you feed your dog treats?

YesNo
If yes, brand and how many per day?
17. What kind of exercise does your dog get?
18. Does your dog scratch, bite at its skin or seem “itchy”?

YesNo
19. Have you noticed

Any weight loss or gain? Any change in your dog’s skin or hair coat? Any recent change in your dog’s behavior or activity level? Any signs of pain, like slow to get up or down, tremor or weakness in the rear legs, protecting of a certain body part? Any recent changes in your dog’s behavior when defecating or urinating?
Please describe the changes:
Should be Empty: