Canine Health Questionnaire Form Owner’s NameDateAddressPostal CodePhone numbers (home)(cell)(work)Email Emerg. Contact(other than immediate family):ph:Pet’s NameBreedColourSexMaleFemaleNeuteredSpayedAge or BirthdayWhat brand of food do you feed your dog? How much do you feed?Where does your dog sleep?What heartworm and flea /tick preventive are you using?Last Administered ?Have you seen any fleas or ticks on your dog?YESNOWhen was your dog’s last dental cleaning under general anaesthesia?Have you noticed any lumps or bumps on your dog?YESNODo you have other pets?YESNOAre they currently vaccinated and on heartworm and flea preventive?YESNOWhat dental care do you provide for your dog ?Does your dog go outside: Daily for Bathroom/Walks 50:50 Indoor/Outdoor Outdoor Dog Does your dog: Come into contact with other dogs (i.e. neighbors dog, dog park) Or go to: Boarding facilities Grooming Dog Parks Obedience/Training Classes Cottage To the U.S.A. OtherAre there any health issues you wish to discuss ?YesNoIf yesAre there any behaviors you wish you could change?YesNoIs your pet currently on ANY medication (inc l. As pirin, glucosamine, etc)?YesNoIf yes, frequency and amounts givenPhoneThis field is for validation purposes and should be left unchanged.
