New Canine Patient FormName(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 NoGoes to a groomer or pet stores with me: Yes NoLives in a wooded area: Yes NoIs taken to the country or a farm, goes camping or is used for hunting: Yes NoGoes to outdoor events or participates in competitions like dog shows: Yes NoIs sometimes visited by or visits other dogs: Yes No. Is or will be attending an obedience or training classes: Yes NoStays in a boarding kennel while we are on vacation: Yes NoLives with or frequently visits immunocompromised person(s) Yes NoPlease indicate if your pet is on Heartworm Preventative: Heartgard Interceptor OtherPlease indicate if your pet is on Flea/Tick Preventative: Frontline Comfortis OtherDo you need a refill for any of the above medications today? Yes NoHas a Microchip: Yes NoPlease answer the following questions about your dog’s recent behavior.Current brand of diet:Appetite is: Normal Decreased IncreasedWeight: Stable Loss GainWater consumption: Normal Decreased IncreasedBowel movements: Normal Constipated DiarrheaUrination: Normal Decreased IncreasedBad Breath: Yes NoVomiting: Yes NoCoughing or gagging: Yes NoCar Sick: Yes NoScooting Currently: Yes NoAny listlessness or weakness: Yes NoShaking head: Yes NoHair loss: Patchy Generalized NoNew lumps or bumps: Yes NoUnusual discharge: Yes NoWhere? Eyes Ears Nose OtherLameness: Yes NoDifficulty rising: Yes NoReluctant to jump: Yes NoAny behavioral changes: Yes NoCAPTCHAΔ