Canine Disease-Risk Assessment
Canine Disease-Risk Assessment
Form & Lifestyle Review
Client Name:__________________________ Date:________________________
Pet’s Name:___________________________ Pet’s Age:____________________
_________________________________________________
Our practice’s goal is to provide you with the up-to-date pet health information
you need to make an informed decision about your pet’s health care!
1. Where does your pet spend it’s time?
⇨ Indoors
⇨ Outdoors
⇨ In and Out
2. How many other pets are in your home? ____
How many dogs? ______
How many cats? _______
Other? _______
3. My dog comes into contact with other pets:
⇨ Yes… ( While boarded in a kennel
( While professionally groomed
( While at a dog park
( While on a walk
⇨ No
4. Is there wildlife in your area, including deer,
mice, squirrels, birds, raccoons, rats, or skunks?
⇨ Yes ( No
5. Do you frequently see mosquitoes near where
your dog goes outdoors?
⇨ Yes ( No
6. Do you hunt with your dog?
⇨ Yes ( No
7. Does your dog have an opportunity to drink from
water outdoors (ponds, puddles, water bowls, etc)?
⇨ Yes ( No
8. Is your dog currently on a heartworm preventive?
⇨ Yes (please list) __________________
⇨ No
9. Is your dog currently on a flea and tick preventive?
⇨ Yes (please list) __________________
⇨ No
10. Is your dog on any medications?
⇨ Yes (please list) __________________
⇨ No
11. Has your dog ever become sick after a vaccination?
⇨ Yes ( No
12. Which best describes your dog’s weight?
⇨ Too thin ( Normal weight
⇨ Gained a few pounds ( Needs to lose weight
13. Which best describes your dog’s breath?
⇨ Not bad for a dog’s breath
⇨ Unpleasant
⇨ Really bad (needs mouthwash)
14. Please check any of the conditions that your pet
has experienced:
⇨ Crying ( Change in behavior
⇨ Eye discharge ( Vision problems
⇨ Hair loss ( Fleas or ticks
⇨ Skin growth ( Change in weight
⇨ Sneezing ( Frequent urination
⇨ Change in appetite ( Increased thirst
15. Do you have pet insurance?
⇨ Yes (Name of Provider ) _______________
⇨ No
__________________________________________________________________________
Based on the Disease-Risk Assessment of your pet, the following vaccines and/or testing are recommended for your pet:
⇨ Rabies Vaccine _____________________ ( Fecal Exam_____________________
⇨ Bordetella Vaccine ___________________ ( Heartworm Test__________________
⇨ Distemper/Parvo Vaccine _____________ ( Bloodwork______________________
⇨ Lyme Vaccine _______________________ ( Other _________________________
⇨ Leptospirosis/Coronavirus Vacc._________
Staff Signature_______________________________________ Date__________________
Stringtown Animal Hospital
1320 Stringtown Rd., Grove City, OH 43123
(614) 871-7705
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