Owner Name:

Pet Name:

Food/Brand and Quantity

Canned, dry or both

Habits: (swimming, hiking, etc.)

Indoor Only: (yes or no)

Outdoor Only: (yes or no)

Both indoor and outdoor: (yes or no)

Total number of household dogs:

Total number of household cats:

Used for hunting: (yes or no)

Does your dog go to a boarding/grooming/daycare/pet store/dog park?: (yes or no)

Change in appetite: (yes or no)

Change in dog's weight recently: (yes or no)

Increased water consumption or urination: (yes or no)

Change in activity level/exercise intolerance: (yes or no)

Limping/slow to get up/reluctance to use stairs: (yes or no)

Vomiting: (yes or no)

Diarrhea: (yes or no)

Straining to urinate or have a bowel movement: (yes or no)

Coughing/difficulty breathing: (yes or no)

Sneezing/nasal discharge: (yes or no)

Itching/hair loss: (yes or no)

Change in behavior: (yes or no, if yes please explain)

Has tested positive for diseases: (yes or no, if yes please list)

Have noticed ear problmes: (yes or no)

On heartworm preventative: (yes or no)

Ticks and/or fleas noted recently: (yes or no)

On tick and/or flea preventative: (yes or no)

Does your dog get car sick: (yes or no)

Regular home dental care: (yes or no)

Have you ever given your dog aspirin, tylenol and/or ibuprofen: (yes or no)

Medications given regularly: (please list)

Heartworm medication: (please list)

Flea medication: (please list)

Has your address or phone number changed since last year: (yes or no) If yes, please provide new information.

Email address:

Best phone number to contact you:

Summary of your concerns:

Appointment date and time