Canine Wellness Assessment Form
Date of your Pet's Appointment
Time of your Pet's Appointment
Doctor Your Pet's Appointment is with?
Please answer these questions so we may customize a wellness / vaccine plan for your dog.
Does your dog socialize with other dogs?
Are those dogs up-to-date on vaccines?
Do you take your dog to parks or other places that other dogs visit frequently?
Does your dog go to a groomer?
Is your dog ever boarded?
Does your dog attend doggie day care?
Does your dog attend agility or obedience classes?
Does your dog travel with you to other states?
Is your dog on a farm or does he / she visit a farm?
Does your pet go hunting or on field trails?
Do you observe wild animals or other wildlife in your area?
Does anyone with compromised immune systems live in or visit your home?
Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?
Does your dog scratch / bite at it's skin or seem itchy?
Have you noticed any weight loss or gain?
Any change in your dog's skin or hair coat?
Any recent change in your dog's behavior or activity level?
Any signs of pain. like slow to get up or down, tremor or weakness in the rear legs, or protecting a certain body part?
Any recent changes in your dog's behavior when defecating or urinating?
Has your dog had an adverse reaction to vaccines in the past?
Approximately how much time does your pet spend outdoors?
2 hours or less
Please check off the parasite prevention you are currently using
Frontline Brand Products
Date of Last parasite prevention given
How many dogs live in your home?
How many cats live in your home?
What kind of food do you feed your pet?
What treats do you feed your pet?
What type of exercise does your dog receive and how often?
Thank you for helping us establish the correct preventative health care protocol for your dog.
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