Canine Annual Wellness Pre-Exam History Form in Crosslake, MN

Name*

First Last

Pet's Name*

Phone*

Have there been any changes to your dog’s behavior since his/her last wellness exam? Does your pet have any specific anxiety or phobia concerns?*

What brand of food do you feed your dog and how much volume of that food does your dog eat per day?*

Any special treats your dog receives on a routine basis?*

Have there been any changes to your dog’s eating or drinking habits?*

Is your dog urinating and defecating normally without any pain or discomfort?*

Yes
No

Comments

Is your dog urinating more than normal or in abnormal locations?*

Yes
No

Comments

Has your pet had any vomiting or diarrhea recently? Does your pet have any history of consistent vomiting/diarrhea from time to time? If so, how often, on average?*

Has your dog been exhibiting any coughing, sneezing you are concerned about?*

Yes
No

Comments

Is there any abnormal eye discharge that you have noted?*

Yes
No

Comments

Does your dog have any occasional or continual limping you have noted?*

Yes
No

Comments

Is your pet itchy, shaking his/her ears, or have any skin concerns today?*

Yes
No

Comments

Have you noted any new lumps or bumps on your pet you are worried about? Any previously discussed lumps that are changing significantly since the last wellness exam?*

Yes
No

Comments

Please indicate which products your dog receives for routine heartworm prevention as well as flea and tick control. Please also note whether you give these products continually (i.e. monthly), or if not, which months your dog is not receiving these products.

Is your dog on any other prescription medications or supplements? If so, please list each medication you administer.