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Client's Name

Pet's Name

Phone Number

Email Address

notes

As your pet ages, changes take place that may indicate medical problems. We are believers in preventing illness rather than treating illness. Since your pet can't talk to us, please take a moment to tell us about your pet.

Daytime Environment

Indoors
Outdoors
Apt. Environment

Does your pet go to

Groomer
Boarding
Training
Park

Does your pet have a history of vaccine reactions?

Does your pet have a microchip?

Are there other pets in the household?

Do you give your pet any medications or nutritional supplements?

If yes, please list any medications and/or supplements.

Do you give your pet heartworm prevention?

If yes, please specify which heartworm preventative you are using.

Last date given?

Have you noticed any changes in food consumption in the last year?

Have you noticed any changes in water consumption in the last year?

Have you noticed any weight loss or gain in the last year?

Have you noticed any activity level or exercise tolerance changes?

Does your pet walk have difficulty walking, stiffness or pain?

Does your pet have any problems hearing?

Does your pet shake its head or scratch its ears?

Are there any lumps or skin lesions?

Is there a flea or tick problem?

Is your pet scratching, chewing or licking itself excessively?

Is your pet scooting or chewing/licking under tail?

Does your pet have eye discharge or red eyes?

Do you clean your pet’s eyes regularly?

Does your pet cough, sneeze or have difficulty breathing?

Do you clean your pet’s ears regularly?

If yes, how often and with what?

Does your pet have seizures or fainting episodes?

Has there been any vomiting?

Has there been any diarrhea?

If yes, when?

How is the smell of your pet’s breath?

Pleasant
Unpleasant
Normal

What brand of food are you feeding your pet?

How much are you feeding daily?

What kind of treats are you giving your pet?