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Canine Wellness Questionnaire
Canine Wellness Questionnaire
21
Questions
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1
Your Name
*
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First Name
Last Name
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2
Pet's Name
*
This field is required.
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3
Email
example@example.com
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4
Phone Number
Area Code
Phone Number
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5
What is the date and time of your appointment?
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6
Has your dog had any prior drug, vaccine reactions, or do you know of any allergies?
*
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7
Please list all the current medications and supplements you give your dog (including heart worm, flea & tick medications & if they missed any doses)
*
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8
Have you missed any doses?
YES
NO
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9
Do you need any refills on the medications you listed?
YES
NO
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10
What do you feed your dog: (Please include food brands, the quantity, & the feeding frequency)
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11
Is this diet grain free?
YES
NO
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12
Does your dog visit dog parks, day care, groomers, or boarding facilities?
YES
NO
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13
Is he/she exposed to areas that have wildlife? (Such as squirrels, raccoons, skunks, deer, etc.)
YES
NO
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14
Have you seen fleas or ticks on your dog, or have you removed any over the last year?
YES
NO
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15
Are there other household pets? If so please list what kind and how many
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16
Is your dog microchipped?
YES
NO
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17
Can you please bring a fresh stool sample?
YES
NO
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18
Does he/she resent being handled, picked-up or is fearful in any way?
YES
NO
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19
Any coughing, sneezing, vomiting or diarrhea? If so, please elaborate.
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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?
YES
NO
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21
Do you have any concerns to address with us?
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