Wellness Form Download Form Owner Name(Required) Email(Required) Phone(Required)Patient Name(Required) Patient QuestionsHow long has your pet been living with you?(Required) Does your pet live:(Required) Indoor Outdoor Both Travel History (outside Manitoba) over the past year:(Required) Yes No DetailsAny planned or potential travel outside of Manitoba in the coming year?(Required) Yes No DetailsAny major household changes (i.e., new house, new job/schedule, new people/baby, renovations)?(Required) Yes No DetailsDoes your pet live or interact with any other types of animals:(Required) Yes No DetailsHas your pet been to the Emergency Vet since your last visit?(Required) Yes No DetailsPrevious Vaccine or Drug Reactions:(Required) Yes No Unknown Is your pet on Heartworm Prevention (June-November):(Required) Yes No Picking up at appointment Is your pet on Tick Prevention (March-November):(Required) Yes No Picking up at appointment Is your pet currently diagnosed with any illnesses?(Required) Yes No DetailsIs your pet currently receiving any medication or supplements?(Required) Yes No DetailsWould 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 file N/A I would like more information NutritionDry 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? Yes No DetailsWould you like a nutritional recommendation? Yes No Fecal ScorePlease enter a number from 1 to 7.View Fecal Score ChartHow often do you brush your pets teeth: Does your pet have any of the following: Coughing Sneezing Vomiting Diarrhea Changes in thirst Changes in appetite Changes in urination Changes in bowel movement Changes in activity level Limping or Stiffness Vision Changes Hearing Changes Increased shedding, licking, scratching Changes in sleeping patterns Behaviour changes Changes in interactions with people or other pets Weight Changes New lumps or bumps Change in odor Does your pet go to any of the following locations Grooming Boarding Training Daycare Dog Shows Dog Parks Interact with children under 5 years of age Interact immunocompromised individuals Interact with seniors Hunting Hiking Camping Around livestock animals Around any areas with lots of vermin Swims, wades or drinks from rivers, lakes, ponds, puddles CAPTCHA Δ