Wellness FormWellness Form Download PDF Client and Patient Information Owner Name* Email Address* Phone Number* Patient Name*Patient Questions How long has your pet been living with you? * Does your pet live: *IndoorOutdoorBoth Travel History (outside Manitoba) over the past year: *YesNo Details: Any planned or potential travel outside of Manitoba in the coming year? *YesNo Details: Any major household changes (i.e., new house, new job/schedule, new people/baby, renovations)? *YesNo Details: Does your pet live or interact with any other types of animals: *YesNo Details: Has your pet been to the Emergency Vet since your last visit? *YesNo Details: Previous Vaccine or Drug Reactions: *NoUnknownYes Details: Is your pet on Heartworm Prevention (June-November): *YesNoPicking up at appointment Is your pet on Tick Prevention (March-November): *YesNoPicking up at appointment Is your pet currently diagnosed with any illnesses? *YesNo If yes, please indicate what illness: * Is your pet currently receiving any medication or supplements? *YesNo If yes, please list the medications and the dosage and the last time they received this medication: * Would like to include any other points of your pet's history? Is your pet having other issues that you would like our veterinarian to check? Who is your pet insurance provider and plan number?Already on fileN/AI would like more information Can we use pet photos online?YesNoNutrition Dry Food Brand: Fed Since: Amount: Feedings/day: Wet Food Brand: Fed Since: Amount: Feedings/day: Other Food/Treats (include quantity and frequency): Do you have concerns about your current nutritional plan? YesNo Details: Would you like a nutritional recommendation? YesNo Fecal Score: / 7 see chart How often do you brush your pets teeth: Does your pet have any of the following: Coughing YesNo Sneezing YesNo Vomiting YesNo Diarrhea YesNo Changes in thirst YesNo Changes in appetite YesNo Changes in urination YesNo Changes in bowel movement YesNo Changes in activity level YesNo Limping or Stiffness YesNo Vision Changes YesNo Hearing Changes YesNo Increased shedding, licking, scratching YesNo Changes in sleeping patterns YesNo Behaviour changes YesNo Changes in interactions with people or other pets YesNo Weight Changes YesNo New lumps or bumps YesNo Change in odor YesNoDoes your pet go to any of the following locations Grooming YesNo Boarding YesNo Training YesNo Daycare YesNo Dog Shows YesNo Dog Parks YesNo Interact with children under 5 years of age YesNo Interact immunocompromised individuals YesNo Interact with seniors YesNo Hunting YesNo Hiking YesNo Camping YesNo Around livestock animals YesNo Around any areas with lots of vermin YesNo Swims, wades or drinks from rivers, lakes, ponds, puddles YesNo Δ
