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Canine Wellness Questionnaire

Please answer yes or no to the following questions

Client Information

Client Name(Required)

Date of Appointment(Required)

Phone(Required)

Email(Required)

Pet information

Pet's Name(Required)

Lifestyle(Required)

Diet and Feeding Schedule(Required)

Has your pet had any change in water consumption?(Required)

Yes

No

Has your pet had any changes in eating habits or appetite?(Required)

Yes

No

Is your pet urinating or defecating in inappropriate places?(Required)

Yes

No

Has your pet had any change in urine production?(Required)

Yes

No

Is your pet leaving wet spots where he/she sleeps?(Required)

Yes

No

Have you noticed your pet having consistent diarrhea?(Required)

Yes

No

Have you noticed your pet having consistent vomiting?(Required)

Yes

No

Is your pet drooling, having bad breath or difficulty eating?(Required)

Yes

No

Have you noticed any change in your pets hair coat?(Required)

Yes

No

Have you noticed your pet having a decrease in vision?(Required)

Yes

No

Have you noticed your pet having a decrease in hearing?(Required)

Yes

No

Have you noticed your pet coughing or having abnormal breathing?(Required)

Yes

No

Is your pet tiring easily during exercise?(Required)

Yes

No

Have you noticed any cognitive issues or behavioral changes?(Required)

Yes

No

Have you noticed any limping, stiffness, weakness or signs of pain?(Required)

Yes

No

please note for how long and which leg.

Have you noticed any new lumps or bumps on your pet? (If so, please note below the location)(Required)

Yes

No

Please note the location of an lump or bumps on your pet.

Has your pet exhibited any signs of anxiety?(Required)

Yes

No

Have your pets sleeping habits changed?(Required)

Yes

No

Please list and medications and/or supplements.(Required)

Please note any other health concerns that your pet may have.

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