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Home » Forms » Canine Health Questionnaire

Canine Health Questionnaire

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Is your dog ever outside unsupervised?(Required)

Does your dog ever come in contact with other pets or their environments?(Required)

Is wildlife in your area, including mice, squirrels, birds, possums, raccoons or skunks?(Required)

Do you ever take your dog to dog shows?(Required)

Do you ever take your dog to the pet store?(Required)

Do you take your dog to a grooming or boarding facility?(Required)

Do you hunt with your dog?(Required)

Does your dog travel with you?(Required)

Do you ever handle unvaccinated dogs?(Required)

Has your dog had a heartworm test in the year?(Required)

Has your dog had a stool examination for intestinal parasites in the last year?(Required)

Is your dog currently on heartworm preventative?(Required)

If yes, please list

Is your dog currently on any medication for fleas?(Required)

If yes, please list

Have you found ticks on your dog in the last year?(Required)

Has your dog ever had any adverse reaction to vaccinations?(Required)

Does you dog sleep with you or your children?(Required)

What diet do you feed your dog?(Required)

Do you give any supplements (vitamins, herbal/holistic medications etc) to your pet? If yes, please list…

Is your dog currently on any medications, if so what is the dosage you are giving and how often?

Which best describes your dog's breath?(Required)

Which best describes your dog's water consumption(Required)

Please select any conditions that apply to your dog(Required)

Vomiting

Diarrhea

Constipation

Incontinence

Increased thirst

Frequent urination

Difficulty jumping

Limping

Difficulty with stairs

Seizures

Skin growths

Itchy skin

Vision problems

Hearing problems

Behavioral changes

Coughing

Other

None

Owner's Name(Required)

Pet's Name(Required)

Date(Required)

MM slash DD slash YYYY

Do you already have an appointment scheduled with us?(Required)

Yes

What date and time is your appointment?

*Please note that the last available appointment on Saturday’s is 11:45 AM

Date

MM slash DD slash YYYY

Time

Hours

Minutes

AM/PM

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12254 State Line Road,
Leawood, KS 66209

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