Canine Wellness Questionnaire

1

Your Name* This field is required.

First Name

Last Name

2

Pet's Name* This field is required.

3

Email

example@example.com

4

Phone Number

Area Code

Phone Number

5

What is the date and time of your appointment?

6

Has your dog had any prior drug, vaccine reactions, or do you know of any allergies? * This field is required.

7

Please list all the current medications and supplements you give your dog (including heart worm, flea & tick medications & if they missed any doses)* This field is required.

8

Have you missed any doses?

YESNO

9

Do you need any refills on the medications you listed?

YESNO

10

What do you feed your dog: (Please include food brands, the quantity, & the feeding frequency)

11

Is this diet grain free?

YESNO

12

Does your dog visit dog parks, day care, groomers, or boarding facilities?

YESNO

13

Is he/she exposed to areas that have wildlife? (Such as squirrels, raccoons, skunks, deer, etc.)

YESNO

14

Have you seen fleas or ticks on your dog, or have you removed any over the last year?

YESNO

15

Are there other household pets? If so please list what kind and how many

16

Is your dog microchipped?

YESNO

17

Can you please bring a fresh stool sample?

YESNO

18

Does he/she resent being handled, picked-up or is fearful in any way?

YESNO

19

Any coughing, sneezing, vomiting or diarrhea? If so, please elaborate.

20

If your dog is an adult (1 year+), we may perform annual wellness bloodwork that includes a stool sample, urinalysis, and the annual heartworm tests. Is this something we can do at the time of your visit with us?

YESNO

21

Do you have any concerns to address with us?