River Road Animal HospitalDog History QuestionnaireDog History Questionnaire (PDF) We want you to have a great experience here, so please bear with us and tell us about yourself and answer some funny questions: Have you reviewed your contact information (address, phone numbers, etc)? Yes No Still current? Yes No How would you prefer to be contacted:* Email Text Home Phone Cell Phone Work Phone Other: Other: How do you prefer to be addressed (Mr/Mrs/Ms, first name, other): Today are you: Kind of in a rush/prefer to get done and get out of here Not in a rush/interested in lots of information exchange When it comes to your dog’s health/our medical recommendations, do you prefer: general info (D/I) specific info (S/C) When you receive information, do you prefer to: See pictures/ handouts Hear someone explain Demonstration when possible What's your dog's favorite activity? Not Sure Does he/she have any weird/interesting behaviors? Not Sure What is your favorite things about your dog? Not Sure How does your dog feel about visiting the vet: Anxious Neutral Happy/Excited Don't know / Not sure Can your dog have treats during their visit? Yes No Yes, but only Yes, but only Do you think your dog is: Underweight Just right Overweight don't know / Not sure Would you say your dog is: Lazy Active Hyper don't know / Not sure Are there any things about your dog that you don't understand and would like to discuss? Not sure Are there any diseases/conditions you are particularly concerned about/want to guard against? Not sure In what ways would you like your dog to be "better"? Not sure Is there anything we could do to make you feel like a better dog owner? Not sure Would you be interested in a life plan / living will for your dog? Not sure Anything else you'd like us to know?Pet:* Owner:* Date: MM slash DD slash YYYY Weight: Today’s Temp: Today’s Age: Reason for Visit: Routine updates Other: Other: Vaccinations up to date? Yes No Not sure Spayed/Neutered? Yes No Not sure Heartworm preventive used? Last time given: Happy with it? Yes No Flea/Tick control used? Last time applied/given: Working? Yes No How often do you bathe your pet? What shampoo used? Does your pet swim? Yes No If yes, how often? If yes, how often? Any injury or illness recently or that still affects him/her? Yes No Describe: Describe: On any medications/supplements? Yes No Describe: Describe: Any adverse reaction after vaccinations, drugs, or medications: Yes No Describe: Describe: Time outdoors? Daily for bathroom/walks 50:50 Indoor/outdoor Outdoor only Is your dog exposed to other dogs? Yes No (boarding, groomer, obedience class, wolks, shared fence, etc) Other pets in the house? Are your other pets vaccinated and on heartworm and flea and tick preventative, if applicable? Yes No What food does your dog eat? How often? How much per meal? Table scraps? Yes No Treats? Yes No Type: Type: Tell us how your dog is doing!Appetite: Increased Normal Decreased Not sure Water Consumption? Increased Normal Decreased Not sure Weight: Gain Stable Loss Not sure Bowel Movements? Normal Constipated Diarrhea Bloody Urination? Normal Increased Decreased Bloody Significant Hair Loss? Yes No Patchy Generalized Excessive Shedding Lameness? Yes No Which Leg? RF LF RR LR Not sure Stiffness or Difficulty Rising? Yes No After sleeping? Yes No After exercise? Yes No Unusual Lumps or Bumps? Yes No Location: Any Behavioral Changes? Yes No Describe: Vomiting? Yes No Coughing or sneezing Yes No Any Listlessness? Yes No Any Seizures? Yes No Shaking Head? Yes No Scratching/Scooting? Yes No Bad Breath? Yes No Unusual Discharge? Yes No Location: Do you need any flea and tick or heartworm preventative today? Yes No Email:* hCaptcha*
