Canine Health Questionnaire Form Owner’s Name Date Address Postal Code Phone numbers (home) (cell) (work) Email Emerg. Contact(other than immediate family): ph: Pet’s Name Breed Colour Sex Male Female Neutered Spayed Age or Birthday What 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? YES NO When was your dog’s last dental cleaning under general anaesthesia? Do you have other pets? YES NO If yes, please list name, breed, and sex of other petsAre they currently vaccinated and on heartworm and flea preventive? YES NO What dental care do you provide for your dog ? Have you noticed any lumps or bumps on your dog? YES NO If yes, please explainDoes 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. Other Are there any health issues you wish to discuss ? Yes No If yesAre there any behaviors you wish you could change? Yes No If yesIs your pet currently on ANY medication (inc l. As pirin, glucosamine, etc)? Yes No If yes, frequency and amounts given NameThis field is for validation purposes and should be left unchanged.
