NSAC Preventive Care Appointment Questionnaire (K9)

North Suffolk Animal Clinic

Canine Preventive Care Appointment Questionnaire
We are thrilled to have you & your pet with us. To better understand & provide the ultimate care for your companion please carefully review through the following questionnaire for your pet's upcoming appointment.
*

Pet NameLast Name
Appointment Date/Time:*

MonthDayYear
HourMinutesAM/PM Option
My pet's appointment is for;*

Vaccine updatesLab workNail trimAnal gland expressionMedication refills
Please indicate below if you need refills or written prescriptions of any medications or preventions at your appointment. Make sure to provide medication name and quantity desired.*
If not notated, we may not be able to fill the medications/preventions during this appointment.

Nutrition:
What is your dog's regular diet? Brand/Type:*
Please specify if the food is grain-free.
How much/How often?*
Do you feed your dog human food and/or treats? If yes, please list below.*

Medications / Supplements:
What brand Flea/Tick preventative do you give? *
n/a if none
Last date given?

MonthDayYear
Leave blank if n/a
What brand Heartworm preventative do you give? *
n/a if none
Last date given?

MonthDayYear
Leave blank if n/a
Is your pet on any additional medications/supplements? If yes, please list below.*

Medical / Behavioral Health Screening:

These help us evaluate your pet's behavior and medical health.
My Dog;
barks too much at my house guests, dogs in neighborhood or passing neighbors.*
has recently experienced issues with stiffness, trouble jumping, walking or playing.*
plays too rough with humans or pets.*
likes to chew up or consume items which are not to be chewed or consumed by him/her.*
has bad breath, drooling or trouble chewing/swallowing.*
licks often or scoots his/her butt on the floor.*
is itchy often or licks his/her paws frequently.*
has experienced a change in attitude, sleeping patterns.*
has new (or change in) lumps, bumps, skin discolorations or hair loss*

Risk Factors:

These help us evaluate risk for leptospirosis, respiratory infections, tick-borne diseases.
My Dog;
has nose to nose contact with other pets.*
has the opportunity to drink from puddles, ponds or still water.*
goes to the park, plays in the grass/woods or travels out of the area*
swims in ponds, lakes or rivers.*
goes to the groomer or daycare.*

Vaccination Screening:

These help us evaluate your dog's health prior to receiving vaccinations.
Does your dog have known vaccine reactions: hives, allergic reaction, swelling or soreness? If yes, please explain below in additional questions or concerns.*
Is your dog currently experiencing any sneezing, coughing, vomiting or diarrhea?*
Has your dog had any change in water/food consumption?*
Has your pet had any change in urinations/bowel movements?*
Do you have any additional questions or concerns for the doctor? If so, please list below.
If your pet is experiencing medical concerns/issues;

Please notify our office right away.

Preventive care exams are meant for healthy pets who are not currently experiencing any medical concerns/issues. If the doctor is able to address the medical concerns during this appoinment, the exam may become a "sick" exam and would not qualify as a preventive care exam.
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North Suffolk Animal Clinic