Preventative Care Questionnaire

Primary Pet Owner's Name *

First

Last

Pet's Name *

Is your pet currently on any medication? *

Yes
No

If yes, which medications and how often?

Any issues with vomiting, diarrhea, appetite, activity level, behavior, urination, thirst or any other issues you would like to discuss with us today? *

Yes
No

If yes, explain:

Any significant weight loss or gain? *

Yes
No

If yes, explain:

Have you changed your pet’s diet? *

Yes
No

If yes, explain:

Are you planning on grooming, boarding, traveling, visiting dog parks, or showing your pet within the next year? *

Yes
No

If yes, explain:

Have you or your neighbors noticed any fleas or ticks within the past year? *

Yes
No

If yes, explain:

Heartworm disease is not just a health concern for dogs, but cats as well. It is transmitted by infected mosquitoes. Check all that apply:

I have a pool or live near free standing water
I go camping or traveling with my pet outside city limits
I travel with my pet outside of the state
My pet sometimes stays outside
My pet is currently on heartworm prevention

Our doctors strongly recommend that all pets be on heartworm prevention year-round, are you interested in having a heartworm test performed today? *

Yes
No - I am declining this medically recommended test

Are you aware that many of the intestinal parasites that dogs and cats are infected with are transmissible to people, especially small children? Our doctors strongly recommend an annual fecal exam. *

Yes
No - I am declining this medically recommended test

At any age our doctors recommends annual blood testing to monitor your pet for internal illnesses, such as diabetes, liver disease, kidney disease and other metabolic problems that may not be apparent. It is also useful to establish a baseline of normal values for your pet. Would you like to have this performed today? *

Yes
No - I am declining this medically recommended test

Our doctors advocate good dental hygiene and care, Orastrips can detect the amount of periodontal disease present in your pet’s mouth. Would you like to have this performed today? *

Yes
No - I am declining this medically recommended test