Canine Wellness Exam Questionnaire

Our canine wellness visits include a full physical exam, vaccinations, parasite prevention, and discussions about nutrition, behavior, and lifestyle. This questionnaire helps us learn more about your dog’s daily routine and health so we can provide the most personalized care possible.

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About This Form

By completing this Canine Wellness Exam Questionnaire, you give our veterinary team important information about your dog’s health history, habits, and environment. This helps us detect potential concerns early and design a preventive care plan tailored to your dog’s unique needs.

Client Information

Owner's Name *

First

Last

Phone Number *

Please enter a valid phone number.

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet Information

Pet’s Name *

Pet's Date of Birth or Age *

How Is Your Pet’s Appetite? *

How Is Your Pet’s Water Intake? *

Any Changes in Your Pet’s Urination? *

Does Your Pet Have Any Abnormal Licking or Scratching? *

What Brand of Food Do You Feed Your Pet? *

How Much Food Does Your Pet Get (½ Cup, 1 Can) and How Often? *

Does Your Pet Have Any Lumps You Would Like Examined? *

How Is Your Pet’s Energy Level? *

Has Your Pet Ever Had a Reaction to Vaccines? *

Medications

Is Your Pet on Any Medications? *

Include Heartworm and Flea Prevention

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Canine Wellness Exam Questionnaire

About This Form

Client Information

Pet Information

Medications

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