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Canine Risk Exposure Questionnaire
1
Your Name
*
This field is required.
First Name
Last Name
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2
Your Pet's Name
*
This field is required.
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3
Contact number for today:
Area Code
Phone Number
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4
You can upload a photo of your dog here. This photo will be attached to their medical record.
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5
Does your pet visit any of the following?
*
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Dog Parks
Grooming Facility
Boarding Facility
Daycare
None of the above
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6
Does your pet ever travel with you out of town?
*
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Yes
No
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7
Do you observe wildlife in your yard, other than squirrels or birds?
*
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Yes
No
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8
Have you seen any evidence of fleas, ticks or parasites on ANY of your pets?
*
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Yes
No
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9
What brand/type of food are you currently feeding?
*
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10
List all medications your dog is on, including flea and heartworm prevention:
*
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11
When was your dog's last dose of heartworm prevention?
-
Date
Year
Month
Day
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12
Does your pet bite at his/her skin or seem itchy?
*
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Yes
No
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13
Have you noticed any weight gain or loss in your pet?
*
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Weight Gain
Weight Loss
Neither
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14
Have you noticed any changes in behavior or activity level?
*
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Behavioral change
Activity Level
Neither
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15
Have you noticed any signs of pain or discomfort?
*
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Weakness in rear legs
Tremors/shaking
Slow getting up and down
No pain or discomfort
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16
Have you seen any changes in behavior when urinating or defecating?
*
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Urinating
Defecating
Neither
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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
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18
Does your pet need any additional services today? ie. nail trim
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19
Any additional notes or issues you'd like to relay to the doctor:
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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?
*
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Additional Charges will apply.
Yes
No
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