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Your Name
Date
Phone Number
Email
Pet's Name
Lifestyle
Indoor Only
Mostly Indoor
Mostly Outdoor
Indoor and Outdoor
Appetite
Very Good
Good
Erratic
Picky
Poor
Very Poor
Diet
Change in appetite?
No Change
More
Less
Feeding
Eats specific meals
Fed free choice
% table food
% treats
% dog food
Water Consumption
Drinks normally
Drinks less than normal
Drinks more than normal
Urination
Normal amount
Less than normal
More than normal
Gets up at night to urinate
Activity Level
Very active
Normal
Very inactive
Change in activity
More active
Less active
Social Activities
Boarding Kennel
Dog Groomer
Dog Parks
Any growths, lumps or bumps?
Yes
No
Where are they located and when did you notice them?
Lameness or Limping?
Yes
No
Which legs?
How often does this occur?
Constant
Intermittent
Trouble Getting up, Jumping or Moving About?
Yes
No
How often does this occur?
Constant
Intermittent
Behavior Changes
Yes
No
If yes, please explain
Seizures
Yes
No
How often
How long in duration?
Vomiting
Yes
No
If yes, how often and what does it consist of?
Is there a relationship to eating?
Yes
No
How?
Diarrhea
Yes
No
How often?
Constant
Intermittent
Number of bowel movements per day
Straining to defecate?
Yes
No
Coughing
Yes
No
How often?
Constant
Intermittent
Difficulty Breathing
Yes
No
How often?
Constant
Intermittent
Sneezing
Yes
No
How often?
Constant
Intermittent
Nasal Discharge
Yes
No
How often?
Constant
Intermittent
Describe
How long?
Itching
Yes
No
How often?
Seasonal
Year-round
Sores present?
Yes
No
Location(s) on body
On a scale of 1 to 10, how bad is it?
1
2
3
4
5
6
7
8
9
10
History of fight wounds
How many times in the past 2 years
Has tested positive for Heartworms
Yes
No
If yes, how long ago?
Has tested positive for Lyme Disease
Yes
No
If yes, how long ago?
Fleas or ticks noted recently?
Yes
No
Is your dog Microchipped?
Yes
No
If not, would you like a microchip inserted today?
Yes
No
Is your dog covered by Pet Insurance?
Yes
No
If so, which carrier
Is your dog jumping like they did in the past?
Yes
No
Have you noticed any change in grooming habits?
Yes
No
Is your dog on a heartworm preventive?
Yes
No
Number of months/years
Name of heartworm preventive
Sentinel
Nexgard
Heartgard
ProHeart
Other
Other
Is your dog on a flea preventive?
Yes
No
Number of months/years
Name of heartworm preventive
Sentinel
Nexgard
Heartgard
ProHeart
Other
Other
Medications or Supplements regularly taken
Summary of your concerns
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