Annual Dog Health Form

Annual Dog Health Form
Name*

First NameLast Name
Pet's Name *
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
My dog spends most of their time:*

IndoorsOutdoorsInside/outside equallyStays in a fenced yardLoose on farm
Have you seen wildlife (raccoons, opossums, rats, mice, foxes, or skunks) anywhere your dog spends time outdoors?*

YesNo
My dog comes into contact with other dogs....*

While at homeWhile professionally being groomed/ bathedWhile boardingWhile at dog parkWhile at dog showWhile out shopping
My dog comes into contact with children?*

YesNo
Do you feed your dog at set feeding times*

YesNo, I free feed through out day.
What are you feeding your dog? Please include any table food or treats they get routinely.*
Describe your dog's weight best...*

Too thinNormal weightGained a few pounds since last visitNeeds to lose weight
Which best describes your dog's breath?(please choose one)*

Not bad for a dog's breathUnpleasantReally bad (Yuck)
Which best describes your dog's water consumption?*

Same as last yearMore than last year
Please check any of the conditions that your dog has experienced in the last year. (Check all that applies)*

Eye dischargeVision problemsNew skin growth or change in a current growth.Itching or chewingHair lossChange in appetiteincreased thirstChange in weightLeaking or dribbling urineFrequent urinationSneezingCoughingChange in behaviorNONE
Is your dog experiencing limping, stiffness when rising, or pain when going up or down stairs?*

NoYes
What heartworm / flea control is your pet currently on? *
If not on heartworm or flea control type None
Is your dog currently taking any medications, other than ones dispensed from our hospital?*

NoYes
Please list medication you need refilled today.*
Please list any issues you would like for our veterinarian to address.*
Should be Empty: