Annual Dog Health Form
Name
*
First Name
Last Name
Pet's Name
*
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
My dog spends most of their time:
*
Indoors
Outdoors
Inside/outside equally
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?
*
Yes
No
My dog comes into contact with other dogs....
*
While at home
While professionally being groomed/ bathed
While boarding
While at dog park
While at dog show
While out shopping
My dog comes into contact with children?
*
Yes
No
Do you feed your dog at set feeding times
*
Yes
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...
*
Too thin
Normal weight
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
Unpleasant
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)
*
Eye discharge
Vision problems
New skin growth or change in a current growth.
Itching or chewing
Hair loss
Change in appetite
increased thirst
Change in weight
Leaking or dribbling urine
Frequent urination
Sneezing
Coughing
Change in behavior
NONE
Is your dog experiencing limping, stiffness when rising, or pain when going up or down stairs?
*
No
Yes
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?
*
No
Yes
Please list medication you need refilled today.
*
Please list any issues you would like for our veterinarian to address.
*
Submit
Should be Empty: