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Mon, Tues, Wed, Fri: 8:00am – 5:00pm
Thurs: 8:00am – 6:30pm
Sat, April 11th & 18th: 9am - 12pm
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(603) 369-4446
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First Name
Last Name
Pet's Name
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Phone Number
Please enter a valid phone number.
My dog spends most of their time:
Indoors
Inside/outside equally
Loose on the farm
Outdoors
Stays in a fenced yard
Other…
Enter other…
Have you seen wildlife (raccoons, opossums, rats, mice, foxes, or skunks) anywhere your dog spends time outdoors?
Yes
No
My dog comes into contact with other dogs....
While at home
While Boarding
While at a dog show
While at dog training
While at a dog park
While out shopping
While being professionally groomed/bathed
My dog comes into contact with children?
Yes
No
Is your dog experiencing any of the following?
Vomiting
Diarrhea
Coughing
Sneezing
Decreased Appetite
Do you feed your dog at set feeding times
Yes
No
What are you feeding your dog? (please list type and brand of food and how much you feed including any table food or treats they get routinely.)
Describe your dog's weight best...
Too thin
Gained a few pounds since the last visit
Normal weight
Needs to loose weight
Which best describes your dog's breath? (please choose one)
Not bad for a dog’s breath
Unpleasant
Really bad (Yuck)
Which best describes your dog's water consumption?
Same as last year
More than last year
Please check any of the conditions that your dog has experienced in the last year. (Check all that applies)
Change in appetite
Change in behavior
Change in weight
Coughing
Diarrhea
Decreased Appitite
Eye discharge
Frequent urination
Hair loss
Increased thirst
Itching or chewing
Leaking or dribbling urine
New skin growth or change in a current skin growth
Sneezing
Vision Problems
Vomiting
None
Have you noticed any changes in your dog’s activity level?
No changes
Slightly less active
Much less active
Reluctant to move or exercise
Does your dog have difficulty with any of the following? (check all that apply):
Getting up from lying down
Lying down
Climbing stairs
Jumping into the car or onto furniture
Running or playing
Have you noticed any limping or favoring of a leg?
No
Occasionally
Frequently
Constantly
When is your dog most stiff or uncomfortable?
After rest (e.g., first thing in the morning)
After exercise
All the time
Not observed
How does your dog walk or move?
Normal
Slower than usual
Stiff or short strides
“Bunny hopping” (back legs moving together)
Unsteady or wobbly
Has your dog shown any hesitation or reluctance to do things they used to enjoy?
Yes
No
If yes, what activities?
Does your dog show any signs of pain when touched or handled?
No
Occasionally
Frequently
Have you noticed any of the following? (check all that apply):
Whining or vocalizing when moving
Changes in posture (arched back, tucked tail)
Shifting weight when standing
Muscle loss (especially in hind legs)
None
Any recent injuries or known trauma?
Yes
No
If yes, explain:
Overall, how would you rate your dog’s mobility?
Excellent
Good (minor slowing)
Fair (noticeable difficulty)
Poor (significant mobility issues)
What heartworm / flea control is your pet currently on?
Are you using the prevention year round?
Yes
No
Is your dog currently taking any medications, other than ones dispensed from our hospital?
Yes
No
Please list medication you need refilled today.
Please list any issues you would like for our veterinarian to address.
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