Health Risk Assessment - Canine
Hello! Please help us expedite your check-in process, decrease your wait time, and offer you the best medical care during your Preventative Healthcare Plan Exam, Annual Examination, or Complete Physical Exam, by completing this history form prior to your appointment. You can complete it by yourself, with other family members or in the office, but with a little advance planning we can help lead your attending DVM to develop the best plan for your pet's ongoing healthcare.
Email address *
First & Last Name of Pet Owner *
Your answer
Dog's Name *
Your answer
Updated Contact Information
If you have moved within the last year, or if your phone number or primary email address has changed, please let us know so we can update your records.
Your answer
Does Your Pet Have A Photo On File? *
If you know your pet's photo has been updated, please select "Yes." If you would like to submit a new photo, please send your photo online to office@highlandvet.net, or we we'll be happy to take a picture with a fresh look for your on the day of your appointment.
Is Your Pet Spayed or Neutered? *
If Pet is Not Spayed or Neutered
Please describe if you plan to breed your pet, your pet's prior offspring or litters if applicable, and the date of your pet's last estrus ("heat cycle") if your pet is a female and not spayed. If your pet is not yet spayed or neutered and you do not plan to breed your pet, please indicate if you plan to have your pet spayed or neutered in the future.
Your answer
Current Medications *
If your pet is taking any prescription medications, please list the type and dosage below. For example, if your pet receives meloxicam liquid, you might type "Loxicam 1.5mg/ml - dosage on file." If your pet was prescribed medication previously, but no longer takes the medication, or if the dosage has been adjusted by a veterinarian or at home, you may comment below as well. If your pet takes no medications, simply comment "None" or "N/A"
Your answer
Flea/Tick Medication *
If your pet is taking any prescription or over the counter flea and tick preventatives, please list them below. Please list the most recent date that you believe you administered or applied this medication. If your pet takes no medications, simply comment "None" or "N/A"
Your answer
Heartworm Prevention/Medication *
If your pet is taking any heartworm preventatives, please list them below. Please list the most recent date that you believe we administered or you administered or applied this medication. If your pet takes no medications, simply comment "None" or "N/A"
Your answer
Which Pets Are Treated *
Which of your pets do you treat for fleas, ticks, internal parasites, or heartworms?
Required
Current Supplements or Vitamins *
If your pet is taking any supplements or vitamins, or any integrative medications (i.e. nutriceuticals), please list the type and describe how often your pet receives the supplement below. If your pet tried a supplement previously, but no longer takes the it, you may comment below as well. If your pet takes no vitamins or supplements, simply comment "None" or "N/A"
Your answer
Refills Needed?
If you listed prescription medications, vitamins or supplements in the space above, you may request a refill or for a script to be renewed below. Please indicate the medication or prescription diet you would like to refill, and the amount you would like to have renewed or refilled.
Your answer
Other Pets - Dogs *
How many other dogs live in your home?
Your answer
Other Pets - Cats *
How many cats live in your home?
Your answer
Other Pets - Exotics or Large Animal *
How many other types of pets live in or around your home?
Your answer
Resources - Current Dietary or Meal Plan At Home *
Please list all types of foods or treats (over the counter, prescription, homemade, or "people food"), that the patient receives in an average day or week. For each food or treat, please list the amount the patient receives on an average day or week, and the times during the day that your patient receives a meal. If food is left throughout the day in a feeder simply type "free fed" to indicate meal times.
Your answer
Resources - Sleeping Quarters *
How many hours of the day does your pet receive rest, on average, and where does your pet sleep.
Your answer
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