Dog's name:

Your name:

Email address:

How did your dog become a part of your family? (rescue, stray, breeder, friend/family, etc.)

Have you noticed your dog coughing or sneezing?

If yes, please explain:

Have you noted your dog vomiting or having diarrhea?

If yes, please explain:

Have you noted if your dog has bad-smelling breath or red gums?

If yes, please explain:

Have you noted any changes to your dog's consumption of water or frequency of urination?

If yes, please explain:

Is your dog on a monthly heartworm preventative?

If yes, what brand are you using?

Any missed doses or lapses in coverage?

Is your dog on a monthly flea and tick preventative?

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?

Have you noted any changes in your dog's activity?

If yes, please explain:

Have you noted any new lumps, bumps or sores that you are concerned about?

If yes, please explain:

Do you plan on having your pet boarded or groomed by a professional groomer?

Do you have any questions or concerns to discuss with your doctor?

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:

Medication 1:

Medication 2:

Medication 3:

Is your dog housetrained?

Do you have any concerns, complaints, or problems with urination in the house now?

Do you have any concerns, complaints, or problems with defecation in the house now?

Does your dog destroy any objects or anything else (doors, windows, etc) now?

Does your dog avoid, seem uncomfortable with or otherwise avoid loud noises (storms, fireworks)?

Does your dog mouth anything or anyone?

Does your dog make any sounds about which you are concerned?

Does your dog growl, bark, snarl or bite?

Does your dog pull on the lead or do other things that make it hard for you to walk with a lead?

Have you ever been concerned that your dog is “aggressive” to people?

Have you ever been concerned that your dog is “aggressive” to other dogs?

Have you ever been concerned that your dog is “aggressive” to animals other than dogs?

Has your dog ever bitten anyone, regardless of the circumstances?

Has your dog had any changes in sleep habits?

Has your dog had any changes in eating habits?

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?

Has anyone ever told you that they were afraid of your dog?

Does your pet show any reluctance to get in the carrier or car?

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

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?

If yes, please explain:

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Canine Wellness Screening Form

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