Annual Dog Health Form
Cell Phone Number
My dog spends most of their time:
Stays in a fenced yard
Loose on farm
Have you seen wildlife (raccoons, opossums, rats, mice, foxes, or skunks) anywhere your dog spends time outdoors?
My dog comes into contact with other dogs....
While at home
While professionally being groomed/ bathed
While at dog park
While at dog show
While out shopping
My dog comes into contact with children?
Do you feed your dog at set feeding times
No, 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...
Gained a few pounds since last visit
Needs to lose weight
Which best describes your dog's breath?(please choose one)
Not bad for a dog's breath
Really bad (Yuck)
Which best describes your dog's water consumption?
Same as last year
More than last year
Please check any of the conditions that your dog has experienced in the last year. (Check all that applies)
New skin growth or change in a current growth.
Itching or chewing
Change in appetite
Change in weight
Leaking or dribbling urine
Change in behavior
Is your dog experiencing limping, stiffness when rising, or pain when going up or down stairs?
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?
Please list medication you need refilled today.
Please list any issues you would like for our veterinarian to address.
Should be Empty: