HIGH DESERT CANINE WELLNESS: CUSTOM INTAKE FORM

HIGH DESERT CANINE WELLNESS

CANINE INTAKE FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Dog Name*
Dog Date of Birth*
Dog Age*
What age was you dog when he/she came to live with you?*
Breed*
Dog Weight (approximate if unknown)*
Dog's Weight is considered:*
Gender*
Reproductive Status:*
If Spayed:*
If neutered:*
Age at time of spay/neuter*
Please list any behavioral/emotional/physical problems your dog exhibited after spay/neuter.*
Has your dog ever been pregnant?*
How many litters?*
Please check all vaccines your dog has received (please note that some vaccines such as DHLPP contains 5 vaccines in one: Distemper, Adenovirus, Leptospirosis, Parainfluenza and Parvovirus-check each individual vaccine)*

ParvovirusDistemperBordatellaAdenovirusLeptospriosisParainfluenzaRabiesInfluenzaCovidLymeRattlesnake vaccineOther
Date of last vaccination*
Is your dog currently on any medications or supplements?*
List all medications or supplements *
Has your dog ever had surgery?*
List reason(s) for surgery*
Please list all PREVIOUS medications and supplements (including anesthesia) as well as any flea/tick/heartworm prevention.*
Current diet:*
Explain other*
Brand and daily amount*
What types of chemicals is your dog exposed to?*

Lawn fertilizerWeed killerPest Control ServiceChemical laundry detergentChemical floor cleanerChemical household cleanersScented candlesAir freshenersNone of the aboveOther
Please select any health conditions your dog is currently exhibiting OR has had in the past :*

AllergiesArthritisJoint conditionsCancerDigestive diffculitesEar problems/infectionsEye drainageEye infectionsHeart problemsReproductive problemsSeizuresItchy skinLicking pawsSmelly coatTeeth problemsHot spotsOther skin conditionsPaws smell like "Fritos"Dry CoatDull CoatThyroid disorderCancerHormone imbalanceAutoimmune disorderUTITraumatic injuryOther
Please select any behavioral problems your dog exhibits:*

AggressionExcessive barkingBitingCompulsive behaviorDominance issuesDoesn't get along with other dogsPacingLickingSeparation anxietyShort attention spanHyperactivityReactivityFear of waterNone of the aboveOther
Please describe your dog's lifestyle: What a typical day looks like for your dog such as: How much outdoor time he/she gets, how much exercise, how much training, whether your dog has a fenced in yard, what size yard, other animals in the home, where your dog sleeps, your dog's favorite toys, activities, how much time is spent home alone and any other relevant information.*
What are your concerns regarding your dog's health?*
What are your goals for your dog's health?*
SUMMARY: Please check each box that applies to your dog:

Received core vaccines from breederReceived dewormer from breederBreeder weaned puppies to kibbleContinued vaccine schedule with vet after bringing puppy homeFed a kibble dietReceived dewormer in your careReceived heartworm preventionReceived Flea/Tick preventionWas prescribed antibioticsWas prescribed allergy medicationWas prescribed anxiety medicationWas prescribed other medicationsReceived AnesthesiaHad X-raysIs spayed/neuteredHad Gastoplexy at time of spay/neuter (or any other time)Had surgery other than spay/neuterWas given supplementsOther
On a scale of 1-10, how would you rate your knowledge of natural rearing principles, including raw feeding. 10 being extensive knowledge.
Should be Empty: