Name Dog's Name Age Sex Spayed/Neutered? Yes No Is your dog currently on heartworm preventative? Yes No Not Sure If yes, date of last dose: Is your dog currently using flea/tick prevention? Yes No Not Sure If yes, date of last dose: What brand of food do you feed your dog? Food Type Dry food/kibble Wet food Both wet and dry food Home-cooked Is your dog on any medications or supplements? If so, please list here: How often do you feed your dog? Once per day Twice per day (In the morning and evening) Free feed (food is available at all times) Do you feed your dog treats? Yes No Type and Frequency of Treats Does your dog (check all that apply)… Sit on a deck or patio Sleep in the bed with you or other family members Play with other pets Play with children Board at a facility when you are out of town Socialize with other dogs, such as at a Dog Park Get groomed at a grooming facility Behavior/Neurologic My dog is just not acting like himself/herself My dog interacts less with the family My dog seems confused or disoriented My dog has been vocalizing for no apparent reason or more than normal My dog’s sleeping patterns have changed My dog has had tremors or episodes of shaking My dog has displayed circling, head tilts, or repetitive movements Other If other, please explain Body Functions My dog has bad breath and red or swollen gums My dog has difficulty chewing My dog’s eating habits have changed My dog has gained weight My dog has lost weight My dog is drinking more water than usual My dog is urinating more frequently than usual My dog’s bowel habits have changed (increased frequency, diarrhea, constipation, straining) My dog vomits more than occasionally My dog seems to have trouble seeing or hearing Other If other, please explain Heart/Lungs My dog seems to be panting more My dog has been coughing or sneezing My dog tires more rapidly or seems short of breath Other If other, please explain Activity Level/Pain Assessment My dog has difficulty jumping to the couch/bed I have noticed a change in my dog’s activity level My dog seems to be limping and/or seems stiff and has difficulty rising from a resting position My dog has been unusually quiet My dog has been vocalizing more than normal Other If other, please explain Skin and Coat My dog scratches, licks, and chews excessively My dog has changes in coat/skin, or has new lumps or bumps My dog’s skin has an odor Other If other, please explain Δ
