New Canine Patient Form Name(Required) First Last Pet NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone(Required)Work PhoneEmail(Required) Recent History & Risk Factor EvaluationSince your last visit, some aspects of your dog’s lifestyle might have changed. We’ll use this information to help evaluate your dog’s health and individualize the care your dog receives, including vaccinations and examinations. Please indicate by circling which items below describe your dog’s lifestyle. My Dog:Is taken for walks or goes to dog parks or parks for exercise and play: Yes No Goes to a groomer or pet stores with me: Yes No Lives in a wooded area: Yes No Is taken to the country or a farm, goes camping or is used for hunting: Yes No Goes to outdoor events or participates in competitions like dog shows: Yes No Is sometimes visited by or visits other dogs: Yes No . Is or will be attending an obedience or training classes: Yes No Stays in a boarding kennel while we are on vacation: Yes No Lives with or frequently visits immunocompromised person(s) Yes No Please indicate if your pet is on Heartworm Preventative: Heartgard Interceptor Other Please indicate if your pet is on Flea/Tick Preventative: Frontline Comfortis Other Do you need a refill for any of the above medications today? Yes No Has a Microchip: Yes No Please answer the following questions about your dog’s recent behavior.Current brand of diet:Appetite is: Normal Decreased Increased Weight: Stable Loss Gain Water consumption: Normal Decreased Increased Bowel movements: Normal Constipated Diarrhea Urination: Normal Decreased Increased Bad Breath: Yes No Vomiting: Yes No Coughing or gagging: Yes No Car Sick: Yes No Scooting Currently: Yes No Any listlessness or weakness: Yes No Shaking head: Yes No Hair loss: Patchy Generalized No New lumps or bumps: Yes No Unusual discharge: Yes No Where? Eyes Ears Nose Other Lameness: Yes No Difficulty rising: Yes No Reluctant to jump: Yes No Any behavioral changes: Yes No CAPTCHA Δ