Preventative Care Questionnaire Primary Pet Owner's Name *FirstLastPet's Name *Is your pet currently on any medication? *YesNoIf 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? *YesNoIf yes, explain:Any significant weight loss or gain? *YesNoIf yes, explain: Have you changed your pet’s diet? *YesNoIf yes, explain:Are you planning on grooming, boarding, traveling, visiting dog parks, or showing your pet within the next year? *YesNoIf yes, explain: Have you or your neighbors noticed any fleas or ticks within the past year? *YesNoIf 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 waterI go camping or traveling with my pet outside city limitsI travel with my pet outside of the stateMy pet sometimes stays outsideMy pet is currently on heartworm preventionOur doctors strongly recommend that all pets be on heartworm prevention year-round, are you interested in having a heartworm test performed today? *YesNo - I am declining this medically recommended testAre 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. *YesNo - I am declining this medically recommended testAt 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? *YesNo - I am declining this medically recommended testOur 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? *YesNo - I am declining this medically recommended testWebsiteSubmit