St. Vital - Vaccine/Annual Wellness Questionnaire

Vaccine/Annual Wellness Questionnaire

To help us with your pet's upcoming appointment, please take a few moments to complete the following questionnaire.
Pet's Name: *
Owner Name: *

First Name Last Name
Date and time of appointment: *

Has your pet experienced any of the following? *

Yes

If yes, please describe:

Weight change

Coughing

Sneezing

Itching

Problems with urination

Vomiting or diarrhea

Decreased or increased appetite

Increased or decreased water consumption

New or growing lumps

Lameness or mobility issues

Please answer the following about your pet's lifestyle.
Where does your pet reside?: *

Indoor Outdoor Both
Is your pet on Heartworm and/or Tick preventatives? *

Yes No
Do you travel with your pet (i.e camping, etc) or go to dog parks, Dog daycare, or boarding? *

Yes No
Please describe your travels:
Do you brush your pet's teeth or use dental care chews or products? *

Yes No
Please describe your dental routine:
Have you noticed any behaviour changes? *

Yes No
Please describe the changes in behaviour:
Your Pet's Diet

Let us know about your pet's diet so we can assess their dietary needs.
Current Diet Type: *
Current Diet Brand: *
Amount Being Fed: *
Treats/Human Food: *
Which formula/flavor does your pet consume? *
If you are unsure, please upload a photo of the bag/cans of food:

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Eating Habits: *
How is your pet's food measured per meal or are they free fed? *
Activity Level: *
What is your pet's current diet type? *

Dry Canned Dry & Canned (both)
Is your pet on any long term medications or supplements? *

Yes No
Please provide the name of the medications/supplements, dosage, and frequency given:
If you are unsure of the name, dosage, and frequency of the medication, please send us a picture:

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Additional concerns (please be as detailed as possible):
Thank you for taking the time to complete this form.
If you have any questions, please give us a call at 204.253.2668.
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Vaccine/Annual Wellness Questionnaire