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Canine Lifestyle Survey
To help us better understand your pets overall health it is important to know some basic information regarding your pet and their history and life style.
Owner's Information
Date
*
Owners Name
*
First Name
Last Name
Address
*
Number and Street
Apt
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
ejemplo@ejemplo.com
Primary Number:
*
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Pet's Information
Pet's Name
*
Upload a picture of your pet (Optional)
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Pet's Age
*
Date of birth (If known)
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2026
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2020
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Year
Pet's Breed ? (Chihuahua, German Shepard, Mixed , etc.)
*
Fur Color/Distinguished Marks
*
Sex
*
Male
Male, Neutered
Female
Female, Spayed
Has she had puppies? If so, how many litters, and when?
*
When was the last time she was in heat?
*
What was his/her age when he/she got neutered/spayed?
*
Is your pet microchipped?
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Yes
No
I'm not sure
Microchip number (If any)
Has your pet had a allergic reaction to any medication?
*
Yes
No
Please explain in full detail if your pet has had any allergic reactions to any medication. What medication? What type of reaction? When did this happen?
Has you pet had any vaccine reactions?
*
Yes
No
Please explain in detail of any vaccine reactions your pet has had. What vaccine? What type of reaction? When did it happen?
Is there any wildlife in your area? Bats, feral dogs, cats, chipmunks, skunks, coyotes, squirrels, etc..
*
Yes
No
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Travel & Outdoors
How much time does your pet spend outdoors?
*
Is your pet free to roam outside? (In a fenced yard)
*
Yes
No
Do you take your pet to the following places? (check all that apply)
Boarding Facilities
Grooming Facilities
Dog Parks
Doggy Daycare
Obedience Training
Organized competitions
Regular dog walks
Do you take your pet along for any of these activities? (Check all that apply.)
Hiking
Camping
Fishing
Hunting
Do you travel with your pet? If so, where (out of state?) and how often?
*
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Vaccines & Preventatives
Has your pet been seen by another veterinarian and/or had vaccines somewhere other than Bosque Animal Clinic?
*
Yes
No
Where did your pet get their last set of vaccines? Veterinarian/clinic name?
*
When was your pet's last heartworm test?
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Is your pet on heartworm preventative?
*
Yes
No
What heartworm prevention do you use?
*
Heartgard
Interceptor
Revolution
Simparica Trio
Proheart Injection
Other
Do you give heartworm preventative year around?
*
Yes
No
Where do you purchase your heartworm prevention?
*
Has your dog ever been tested for tick born disease? If so, when?
*
Is your pet on flea/tick preventative?
*
Yes
No
What flea/tick preventative do you use?
*
Do you give flea and tick preventative year around?
*
Yes
No
Where do you purchase your flea/tick preventative?
*
When was your pet's last fecal exam to test for zoonotic intestinal parasites (roundworms, hookworms, tapeworms, whipworms, giardia, etc)?
*
Do you do anything for your pet's oral health? Brush teeth? Provide dental chews/treats or products? If so, please provide us details. How often do you brush, give dental chews/treats or use dental products? What are the names of the chews/treats and/or dental products you use for your pet?
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Medical History
Is your pet on any medications (besides heartworm and/or flea/tick prevention)? If so, what, how much and how often?
*
Is your pet on any over the counter supplements? If so, what, how much and how often?
*
Does your pet have any previous medical conditions? If so, please provide us details.
*
Has your pet had any previous surgeries (besides spay/neuter)? If so, please provide us details.
*
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Diet & Appetite
What do you feed your pet?
*
Dry food
Canned food
Home made diet
Raw food
What is the brand of dry food you feed?
*
How much and how often do you feed?
*
Is the food you feed a grain free diet?
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Yes
No
What is the brand of canned food you feed?
*
How much and how often do you feed?
*
Describe the home made or raw diet you give your pet? How much and how often?
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Do you feed your pet any table foods (share your meals with your pet)? If so, what and how often?
*
Were there any recent changes to your pets diet?
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Yes
No
What were the recent changes to your pets diet?
*
How is your pets appetite?
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Normal
Increased
Decreased
Give us details on the changes in your pets appetite? When did it start? Any recent diet changes?
*
How is your pets water intake?
*
Normal
Increased
Decreased
Give us details on the changes in your pets water intake? When did it start?
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Health Status
Have there been any changes to your pet's weight?
*
Weight gain
Weight loss
No, weight is stable
When did you first notice the change in your pet's weight?
Has there been any changes to your pets activity level?
*
Pet has been less active
Pet has been more active
No changes
When did you first notice the change in your pet's activity level?
*
Is your pet having normal and regular bowel movements?
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Yes
No
Please provide us details on your pet's abnormal bowel movements. Diarrhea? Constipation? Increase in frequency?
*
Have you seen any worms in your pets bowel movements? If so, provide us details.
*
Is your pet urinating normally?
*
Yes
No
Please provide us details on your pets abnormal urination. Increase in frequency? Amount? Blood or abnormal odor? Straining?
Is your pet having problems with itching, scratching or excessive licking?
*
Yes
No
Please provide us details on your pet's excessive itching, scratching or excessive licking.
Have you seen any fleas or ticks on your pet?
*
Fleas
Ticks
None
Does your pet have any skin rashes or hair loss?
*
Yes
No
Please provide us details on your pet's rashes. When did it start? Have you applied anything topically or given any medications?
*
Is your pet sneezing, coughing or having breathing problems?
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Yes
No
Please provide us details about your pets sneezing, coughing and/or breathing problems. When did they first start? When do they occur? How often? Are they seasonal? Associated with excitement?
*
Does your pet have any eye or nose discharge?
*
Yes
No
Please provide us details on the eye and/or nose discharge your pet is experiencing. When did it start? How often does it occur? Is it clear, yellow, green? Etc.
*
Have you noticed any problems or changes in your pets vision?
*
Yes
No
Please provide us details about your pets change in vision. When did you first notice the changes?
*
Does your pet have any lumps or bumps?
*
Yes
No
Please provide us details about your pets lumps or bumps? When did you first notice them? Have they gotten bigger? Are they causing pain or discomfort for your pet? Etc.
*
Does your pet have any aches or pains? Slow to rise or lay down? Hesitant to jump on coach, bed or in vehicle?
*
Yes
No
Please provide us details about your pets aches or pains? When did it start? Any associated trauma? Etc.
*
Is there any recent known toxin exposure?
*
Yes
No
Unknown
Please provide us details on your pets recent toxin exposure. What? When? Where?
*
Is there any recent known trauma?
*
Yes
No
Unknown
Please provide us details on your pet's recent trauma. What? When? Where? How?
*
Has your pet had any history of seizures?
*
Yes
No
Please provide us details on your pets seizure history? When did they start? How frequently do they happen? Any known triggers? Any current medications? Any history of head trauma?
*
Has your pet had any changes in behavior or attitude?
*
Yes
No
Please provide us details on the changes in behavior or attitude your pet is changing. When did it start? What changes have occurred? Have you tried any medications or supplements to help?
*
Does your pet suffer from anxiety?
*
Yes
No
Please provide us details on your pets anxiety? When does it happen? How often? Any known triggers? Have you tried any medications , over the counter supplements or behavior modification?
*
What is the primary reason for today's visit?
*
Do you have any specific questions or concerns you would like to address today?
*
Signature
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