CANINE Senior Wellness Exam CANINE Senior Wellness Exam This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:* Your name:* Last visit we gave you information on our health plans. Do you have any questions?*Where does your dog spend most of his/her day? (inside, outside, in a room, in a kennel, with you)?*Have you taken your dog to any training classes? If so, where?*Do you train your dog? If so, how? (with treats, clicker training, etc.)*Do you walk your dog? If so, what type of collar does your dog wear for walks?Do you have any problems with walking your dog?*Have you noticed any changes in your dog’s personality or activity level?* yes no Does your pet have difficulty rising after resting or sitting?* yes no Has your pet had any poop or pee accidents in the house?* yes no Has your dog become more independent, less affectionate, or more dependent?* yes no Is your dog ever disoriented at times or fail to recognize familiar people?* yes no If you have other pets in the household, describe the dog’s relationship with them:*Has your dog ever shown any growling, barking, snarling or mouthing/biting towards you or anyone else? If so, when?*Are there things your dog is afraid of or does not like? If so, please describe:*Has your dog shown any of these signs (click all that apply): coughing sneezing itching diarrhea vomiting lack of appetite Any change in grooming or sleeping habits?*Are change in food/water consumption?*Please rate your pet's itchiness score from 1-10, 1 being not itchy at all, 10 being extremely itchy.*12345678910Any changes in frequency of urination or defecation?* yes, more urinating yes, more defecating no, everything is the same Stool Quality Score*Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.12345Did you bring a stool sample today?* Yes No Has there been a change in energy level in your dog?* yes no unsure What, if any, medications (over the counter or prescription) does your puppy take or have been applied routinely? Upload photos of products, if any. Drop files here or Select files Max. file size: 300 MB. What type of food do you feed your dog and how often is he/she fed?*Is your pet fed a grain-free diet? Yes No Is food available all the time or at set "mealtimes"?What human food/homemade cooking or treats does your pet get?Does your pet attend grooming/boarding/daycare/dog park facilities?* Yes No Does your pet hunt?* Yes No Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?* Yes No Was your pet living in or traveling with you to heartworm/tick endemic area in the last 12 months? (States, south west/Northern Ontario)?* Yes No Is your pet on heartworm prevention? Please also upload any photos of the products your pet is on. Drop files here or Select files Max. file size: 300 MB. Do you have any doses leftover from last year?* Yes No Is your pet on flea/tick prevention currently?* Yes No When was approximate last time you found ticks on your pets, if any? (Date) Would you like us to get your pet started on Lyme vaccine?* Yes No I'd like to know more before I decide How did your pet do after last year's vaccines? Was there any reaction to the vaccines?* Yes No Is your pet microchipped?* Yes No Has your pet bitten any person in the last 10 days which broke the skin?* Yes No Please list any questions/problems/concerns for Dr. Jinni that you would like addressed:Does anyone in your household have a peanut allergy?* Yes No Third Choice Δ