Pet's Name (required) My Pet is a (required) Dog Cat 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) Yes No
1a. If yes, what symptoms did your pet have? 2. Does your pet live indoors only, outdoors only or both indoors/outdoors? (required) Goes Indoors/Outdoors Never Goes Outside Never Goes Inside 2a. If your pet goes outside, is he/she? On a leash In a fenced yard No leash or fenced yard 3. Does your pet go to any of the following: Grooming/Boarding/Dog Parks? (select all that apply) (required) None Doggie Day Care Grooming Dog Parks Pet Stores Boarding 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) Once a day Twice a day Three times a day Leave food in bowl 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) About the same More than usual Less than usual 6. Do you do any dental home care for your pet? (required) None Brush teeth Water Additive Dental Chews 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) Yes No 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) Do not see pet urinate/defecate No changes in either Changes in urination Changes in stool 12b. If yes, please explain what changes you have noticed? 13. Any vomiting and/or diarrhea? (check all that apply) (required) None Vomiting Diarrhea 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) Coughing Sneezing Watery Eyes Runny Nose None 14b. If yes, please indicate how long you have noticed symptoms?