Canine Health Questionnaire (Puppy <1 year of age) Date MM slash DD slash YYYY Owner’s Name:Pronouns (optional)Address Street Address 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)Phone (cell)Phone (work)Email Emergency Contact (other than immediate family):Phone NumberPet’s Name:Breed:Colour:Sex: Male Female Neutered Spayed Age:Birthday: MM slash DD slash YYYY 1. What date did you obtain your puppy? MM slash DD slash YYYY 2. How old was your puppy when you obtained him/her?3. Where did you obtain your puppy? Private Pet store Breeder Shelter/rescue Other 4. Has your puppy received any vaccinations? Please bring documentation. Yes No a. If known, indicate which vaccine and date(s) given:5. Has your puppy received any dewormers? Please bring documentation. Yes No a. If known, indicate name of dewormer and date(s) given:6. Have you noticed any of the following: Lethargy Limping Ticks/Fleas Bad Breath Increased Drinking or Eating Habits Decreased Drinking or Eating Habits Changes in Urination Diarrhea Constipation Coughing or Labored Breathing Sneezing Vomiting Scratching Licking Scooting Head Shaking Lumps or Bumps 7. Is your puppy registered for puppy socialization classes? Yes No a. If so, where?8. Is your puppy house trained? Yes, outdoors only Yes, indoor pee pads or mats No, they are having accidents 9. Where does your puppy stay when you leave them alone? Free in the house They are being crate trained Restricted area in the house via gate or door 10. Did your puppy’s diet change when you brought them home? Yes No 11. What diet are you currently feeding your puppy? Please indicate brand of food, amounts, and how often for each of the following:Dry kibble:Canned food:Treats/other: Add Remove12. Is your puppy currently on ANY supplement or medication (incl. vitamins, probiotics, etc)? Yes No a. If yes, please indicate how often and amounts13. Will your puppy be doing any of the following: Boarding Go to the groomers Travel with you Have contact with other animals Go to dog parks Go to obedience, training, or sport activities Go to the cottage, camping, or forested areas 14. Do you have other pets? Yes No a. If yes, how many and what species?b. If applicable, are they currently vaccinated and on heartworm and parasite preventive? Yes No 15. Is there anyone in contact with your pets who has an immunocompromised condition (ie, diabetes, pregnancy, cancer, children <5yrs, seniors >65yrs)? Yes No 16. Are there any health issues or behaviors you wish to discuss? Yes No a. If yes, please indicate:17. Does your puppy have a microchip, or carry pet insurance? Yes No Microchipped (# if known):Insured (please indicate insurer):