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Pet Portal
Canine Wellness Screening Form
Pet's name:
Your name:
Email address:
How did your pet become a part of your family?
- None -
Rescue
Stray
Breeder
Family/Friend
Have you noticed your dog coughing or sneezing?
- None -
Yes
No
If yes, please explain:
Have you noted your dog vomiting or having diarrhea?
- None -
Yes
No
If yes, please explain:
Have you noted if your dog has bad-smelling breath or red gums?
- None -
Yes
No
If yes, please explain:
Have you noted any changes to your dog's consumption of water or frequency of urination?
- None -
Yes
No
If yes, please explain:
Is your dog on a monthly heartworm preventative?
- None -
Yes
No
If yes, what brand are you using?
Any missed doses or lapses in coverage?
- None -
Yes
No
Is your dog on a monthly flea and tick preventative?
- None -
Yes
No
If yes, what brand are you using?
When was the last dose given?
What brand of food do you feed your dog?
How much do you offer at each feeding?
How often do you offer food?
- None -
Once daily
Twice daily
Three times daily
Free feed throughout the day
Have you noted any changes in your dog's activity?
- None -
Yes
No
If yes, please explain:
Have you noted any new lumps, bumps or sores that you are concerned about?
- None -
Yes
No
If yes, please explain:
Do you plan on having your pet boarded or groomed by a professional groomer?
- None -
Yes
No
Do you have any questions or concerns to discuss with your doctor?
- None -
Yes
No
If yes, please explain:
Do you need a refill of your dog's medication(s) while you are here? If yes, please list the medications below:
- None -
Yes
No
Medication 1:
Medication 2:
Medication 3:
Is your dog housetrained?
- None -
yes
No
Do you have any concerns, complaints, or problems with urination in the house now?
- None -
Yes
No
Do you have any concerns, complaints, or problems with defecation in the house now?
- None -
Yes
No
Does your dog experience periodic bouts of diarrhea?
- None -
Yes
No
Does your dog destroy any objects or anything else (doors, windows, etc) now?
- None -
Yes
No
Does your dog avoid, seem uncomfortable with or otherwise avoid loud noises (storms, fireworks)?
- None -
Yes
No
Does your dog mouth anything or anyone?
- None -
Yes
No
Does your dog make any sounds about which you are concerned?
- None -
Yes
No
Does your dog growl, bark, snarl or bite?
- None -
Yes
No
Does your dog pull on the lead or do other things that make it hard for you to walk with a lead?
- None -
Yes
No
Have you ever been concerned that your dog is “aggressive” to people?
- None -
Yes
No
Have you ever been concerned that your dog is “aggressive” to other dogs?
- None -
Yes
No
Have you ever been concerned that your dog is “aggressive” to animals other than dogs?
- None -
Yes
No
Has your dog ever bitten anyone, regardless of the circumstances?
- None -
Yes
No
Has your dog had any changes in sleep habits?
- None -
Yes
No
Has your dog had any changes in eating habits?
- None -
Yes
No
Has your dog had any changes in locomotor behaviors or its ability to rise after sleeping, get around, climb stairs or jump on the bed, etc?
- None -
Yes
No
Has anyone ever told you that they were afraid of your dog?
- None -
Yes
No
Does your pet show any reluctance to get in the carrier or car?
- None -
Yes
No
How would you describe your pet's behavior during travel? (select all that apply):
Eager & excited
Subdued
More quiet than usual
More vocal than usual
Does your pet do any of the following during travel?(select all that apply):
Pant
Tremble
Pace
Hide
Drool
Vomit
Poop
Pee
Are there any situations that your pet has tried to avoid or seemed to dislike of in the past? (select all that apply):
Entering the vet hospital
Unfamiliar people or animals
Being weighed
Going into the exam room
Being put up on the exam table
Having a rectal temperature taken
Ear exam
Cleaning
Nail trim
Other…
Enter other…
Has your pet ever been given any supplements or prescribed any medications to help manage his/her fear or anxiety associated with the visit? If so, what was it and what sort of results did you experience?
Is the dog exhibiting any behaviors about which you are concerned, worried or would like more information?
- None -
Yes
No
If yes, please explain: