Canine Risk Exposure Questionnaire

1

Your Name* This field is required.

First Name

Last Name

2

Your Pet's Name* This field is required.

3

Contact number for today:

Area Code

Phone Number

4

You can upload a photo of your dog here. This photo will be attached to their medical record.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

5

Does your pet visit any of the following?* This field is required.

Dog Parks

Grooming Facility

Boarding Facility

Daycare

None of the above

6

Does your pet ever travel with you out of town?* This field is required.

Yes

No

7

Do you observe wildlife in your yard, other than squirrels or birds?* This field is required.

Yes

No

8

Have you seen any evidence of fleas, ticks or parasites on ANY of your pets?* This field is required.

Yes

No

9

What brand/type of food are you currently feeding?* This field is required.

10

List all medications your dog is on, including flea and heartworm prevention:* This field is required.

11

When was your dog's last dose of heartworm prevention?

Date

12

Does your pet bite at his/her skin or seem itchy?* This field is required.

Yes

No

13

Have you noticed any weight gain or loss in your pet?* This field is required.

Weight Gain

Weight Loss

Neither

14

Have you noticed any changes in behavior or activity level?* This field is required.

Behavioral change

Activity Level

Neither

15

Have you noticed any signs of pain or discomfort?* This field is required.

Weakness in rear legs

Tremors/shaking

Slow getting up and down

No pain or discomfort

16

Have you seen any changes in behavior when urinating or defecating?* This field is required.

Urinating

Defecating

Neither

17

Do you need a refill of any of the following medications?

Simparica Trio (Heartworm/Flea/Tick Prevention)

Sentinel (Heartworm/Flea birth control)

Bravecto (3 month Flea/Tick prevention)

Proheart 12 (12 month injectable heartworm prevention for dogs)

Proheart 6 (6 month injectable heartworm prevention for dogs)

None

Other

18

Does your pet need any additional services today? ie. nail trim

19

Any additional notes or issues you'd like to relay to the doctor:

20

Along with examination and vaccinations, our doctors recommend an additional labwork and urinalysis panel to detect underlying diseases. Would you like to do that today?* This field is required.Additional Charges will apply.

Yes

No