Pet's Name (required) My Pet is a (required) My pet's birth date or age is (required) What color is your pet? (required) 1. Has your pet had any problems receiving vaccines in the past? (required) 1a. If yes, what symptoms did your pet have? 2. Does your pet live indoors only, outdoors only or both indoors/outdoors? (required) 2a. If your pet goes outside, is he/she? 3. Does your pet go to any of the following: Grooming/Boarding/Dog Parks? (select all that apply) (required) 4. What brand of food do you feed your pet? (required) 4a. Canned and/or Dry food? How much of each do you feed at each meal? (required) 4b. How often do you feed your pet? (required) 4c. Do you give your pet treats? If yes, what kind and how many per day? (required) 4d. Does your pet have any known food allergies? If yes, what is he/she allergic to? (required) 5. Is your pet drinking his/her normal amount of water daily? (required) 6. Do you do any dental home care for your pet? (required) 7. What Heartworm Prevention is your pet currently on? (required) 7a. Has your pet missed any doses? If yes, how many? (required) 8. What day of the month do you give the heartworm prevention? (required) 8a. What flea prevention is your pet on? (required) 8b. Has your pet missed any doses? If yes, how many? (required) 9. What day of the month do you give the flea prevention? (required) 9a. Any other medications or supplements given? (required) 10. Will you need a refill of any medications? (required) 10a. If yes, which medications? 11. Any itching/scratching anywhere or shaking of the head? If yes, please indicate what and where? (required) 12. Have you noticed any changes in your pet's urination or stool (poop)? (required) 12b. If yes, please explain what changes you have noticed? 13. Any vomiting and/or diarrhea? (check all that apply) (required) 13a. If yes, is this a new problem or a reoccurring problem? 13b. How long have you noticed symptoms? How frequently does this occur? 14. Does your pet have any of the following: Coughing/Sneezing/Watery Eyes? (check all that apply) (required) 14b. If yes, please indicate how long you have noticed symptoms?
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