Dog HX Form Your Name First Last Pet Name*Date*DietWhat food are you feeding?How much food are you feeding?How often are you feeding?What / how many treats do you feed your pet?MedicationsWhat medications are you giving your pet?Did you bring them with you?What is the dosage/strength/size/number of pills you are giving?How often do you give it?Do you have difficulty medicating?Are you giving any supplements or other over the counter or human medications?Parasite PreventionWhat parasite preventative are you using?What day of the month do you give it?What flea/tick preventative do you use?Pet InformationIs your pet microchipped?What dental care do you provide at home?Is there any stiffness or reluctance to use stairs?or jumping on furniture?Are there other pets living in your home? What? dog/cat/other Names?How many hours per day does your pet spend outdoors? Indoors?Do you take him/her to Boarding? Grooming? Daycare? Obedience? Agility? Hunting? Camping? Fishing? Other Competitions?Do you travel with your pet? Where?Which of the following do you see in your neighborhood Feral cats Raccoons Squirrels Chipmunks Skunks Small rodents Deer Turkey Coyotes Fox OtherDo you take your pet to visit other homes where there are pets?Do you visit other homes where there are pets?Do other pets come to visit your home?Does anyone with a compromised immune system live in or visit your home?Have you seen evidence of fleas, ticks or worms on any of your pets or in your home?Does your pet need a nail trim?Does your pet need a nail trim?Has your pet been elsewhere for vet care since she/he was last here? If yes where? When? For what?Are there any bumps/skin masses that the doctor should be aware? Where? Has the vet seen it before? Has cytology been performed on it/them?Have you noticed any: Weight loss/Gain Change in skin or coat Recent change in behavior or activity level Any signs of pain like slow to get up/down, tremor or weakness in rear legs, protecting an area of the bodyIf yes, please describeCatching changes early before they become serious often means they will be easier and less expensive to treat. Checking baseline blood and urine is like an extended examination of what’s going on inside. Would you like us to perform these tests today?YesNoDoes your pet have any of the following? Cough Sneezing Diarrhea Vomiting Excessive Urinating Excessive Drinking OtherIf other, describePhoneThis field is for validation purposes and should be left unchanged.
