Canine Annual Physical Questionnaire

Thank you for taking the time to answer these questions. This will help our Veterinarians understand your dog’s diet, lifestyle, and environment.

Name *

First

Last

Pet's Name *

Is your dog on any medications or supplements? *

• Yes
• No

If on medications and supplements, please list.

Appetite *ExcellentGoodPickyPoor

Food Type *KibbleKibble & CannedCanned OnlyRaw

Food Brand *

Diet Frequency *Once DailyTwice DailyThree Times DailyFree Fed

Water Consumption *Drinks normal amountDrinks excessive amountDoesn't drink a lot

Activity Level *NormalHigh energySedentary

Do you have any other pets in your home? If so, please list: *

Do you board your dog or go to a grooming facility, obedience school, leash free parks or pet shows? *NoYes

Does your dog travel with you to destination vacation places (cottage, out of province, USA, etc.): *NoYes

If they do travel with you, please indicate where:

Does your dog hunt? *NoYes

If your dog does hunt, does (s)he eat their prey?NoYes

Does your dog vomit? *My dog does not vomitMy dog vomits occasionallyMy dog vomits excessively

Does your dog persistently cough? *My dog does not coughMy dog coughs occasionallyMy dog coughs excessively

Does your dog persistently sneeze? *My dog does not sneezeMy dog sneezes occasionallyMy dog sneezes excessively

Does your dog persistently itch? *NoSeasonallyYear Round

If your dog does itch, please indicate the location(s) on their body:

Has your dog experienced any mobility issues? *NoYesOn Occasion

If lameness has been noticed, please state which leg(s) and the duration.

Have any fleas or ticks been noticed recently? *NoYes

Do you give your dog parasite prevention? *YesNo

Do you get skunks, raccoons, or rodents in your yard or neighbourhood? *YesNo

Does your dog have access to rivers, lakes or ponds? *YesNo

Have you noticed any lumps you would like to have checked? If so, please include their approximate locations on body: *

Our clinic is 'Fear Free' and the veterinarians and team take into account not only your pet's physical well-being, but also their emotional well-being.

During past veterinary visits, what level would you classify your pet as on the Spectrum of FAS (Fear, Anxiety and Stress)? *FAS 0FAS 0-1FAS 1FAS 2FAS 3FAS 4FAS 5

Should you have any additional concerns, please include them here:

Lastly, please describe which number best describes your pet's stool using the Fecal Scoring Chart linked below: *1234567

View Fecal Scoring Chart

Thank you for your time in helping us understand your pet better. Together we can continue to preserve that special bond!

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