Canine Health Questionnaire (Annual 2-6 years of age) DateOwner’s NamePronouns (optional)Address Street Address Address Line 2 City Province/Region Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (home)(cell)(work)Email Emergency Contact (other than immediate family)PhonePet’s NameBreedColourSex Male Female Neutered Spayed Age or BirthdayALL NEW PETS SHOULD BRING or REQUEST MEDICAL RECORDS BE SENT TO INFO@LYNWOODANIMALHOSPITAL.COM1. Have you noticed any of the following Lethargy Limping Bad breath Increased drinking or eating habits Decreased drinking or eating habits Changes in Urination Accidents in the house Diarrhea Constipation Coughing or Labored Breathing Sneezing Vomiting New (or changing) Lumps or Bumps Scratching Licking Scooting Head shaking 2. What diet are you currently feeding your dog? Please indicate brand of food, amounts, and how often for each of the following:Dry kibbleCanned foodTreats/other Add Remove3. What parasite preventive are you using for your dog? Interceptor Plus Advantix Credelio Nexgard Spectra Other a. Last administered?b. Have you found any ticks or fleas on your dog? Yes No 4. Is your dog currently on ANY supplement or medication (incl. vitamins, probiotics, omegas, glucosamine, etc)? Yes No a. If yes, please indicate how often and amounts5. What type of dental care do you provide for your dog? None Brushing daily/every other day Brushing other Dental diet Dental treats Dental at the groomers Water additive Other 6. Does your dog do any of the following: Boarding Go to the groomers Go to dog parks Travel with You Have contact with other animals Go to obedience, training, or sport activities Go to the cottage, camping, or forested areas 7. Do you have other pets? Yes No a. If yes, how many and what species?b. If applicable, are they currently vaccinated and on parasite preventive? Yes No 8. Is there anyone in contact with your dog who has an immunocompromised condition (ie, diabetes, pregnancy, cancer, children <5yrs, seniors>65yrs)? Yes No 9. Are there any health issues or behaviors you wish to discuss? Yes No a. If yes, please indicate:10. Does your dog have a microchip, or carry pet insurance? Yes No Microchipped (# if known):Insured (please indicate insurer):CommentsThis field is for validation purposes and should be left unchanged.