Canine Questionnaire - Country Chase

Canine Patient Assessment Questionnaire

In order to provide top quality care and service for you and your pet Country Chase Veterinary is asking you to answer the following questions to the best of your ability. This questionnaire will help our doctors make recommendations for your pet based on the risk factors that they face individually. This fits our belief that each patient should be treated as an individual rather than taking a one size fits all approach. We want to vaccinate your pet with only the vaccines they need without over-vaccinating them with vaccines they will not need. We appreciate your help in this process.

First Name(Required)

Last Name(Required)

Patient (Pet) Name(Required)

Is your dog exposed to rodents, raccoons or other animals either face to face or shared spaces? For example, do you have wildlife in the space your pet plays or uses the bathroom?(Required)

Yes

Is your dog likely to swim in or drink from freshwater ponds, lakes, rivers, or puddles?(Required)

Yes

Is your dog having any coughing, sneezing, vomiting or diarrhea?(Required)

Yes

Does your dog travel outside of the state?(Required)

Yes

Does your dog go to dog parks, doggie day care or stores?(Required)

Yes

Does your dog go to a professional Groomer?(Required)

Yes

What do you give your dog for heartworm and flea prevention?

Heartworm Prevention:(Required)

Flea/Tick Prevention:(Required)

Have you missed any doses?(Required)

Yes

Have you noticed any new or growing lumps on your pet?(Required)

Yes

What do you use for home dental care?(Required)

What types and brands of foods and treats do you feed your dog?

Dry kibble(Required)

Amount per day(Required)

Wet(Required)

Amount per day(Required)

Treat/Human Food(Required)

Amount per day(Required)

What other medications and supplements is your dog taking?(Required)

In the event life saving measures are needed, do you authorize us to do so?(Required)

Yes