Pet's Name* Owner's Name* Please complete the following questions about your pet:1. Do you use a heartworm preventative? Yes No If yes, which brand Date last used MM slash DD slash YYYY 2. Do you use a flea/tick preventative? Yes No If yes, which brand Date last used MM slash DD slash YYYY 3. Have you been seeing fleas or ticks on your pet? Yes No 4. Do you have other dogs or cats? Yes No If yes, how many?DogsCats5. Are all your pets currently vaccinated and on heartworm and flea prevention? Yes No If no, please explain*6. What best describes the amount of time your dog/cat spends outdoors? Daily under supervision 50:50 Indoor/outdoor Outdoor only Indoors only 7. Check if your dog/cat does any of the following: board travels with you go to groomers contact with neighborhood dogs/cats dog parks obedience/training classes 8. What brand of food do you feed your pet?BrandHow much?How often? Add Remove9. Do you provide any dental care for your pet? Yes No If yes, please describe*10. Have you noticed any lumps or bumps on your pet? Yes No If yes, please describe*11. Have you noticed any skin or coat problems on your pet? Yes No If yes, please describe*12. Check if you have noticed any of the following: Coughing/labored breathing Limping Tiredness/sluggishness Vomiting Constipation Increase/decrease in weight Increased thirst and/or urination Diarrhea Dry, lusterless fur Other Other* 13. Does your pet have any behaviors you wish you could change? Yes No If yes, please explain*14. Please list any health issues you would like to discuss with the veterinarianHelp us customize your pet’s wellness program! Exposure to other pets: Cats & Dogs: Is your dog or cat primarily outdoors? Yes No Does your dog/cat compete in shows or competitions? Yes No Do you take your dog/cat to a groomer? Yes No Do you ever board your dog/cat? Yes No Cats only! Does your cat go on a screened-in porch? Yes No Do you have other cats in the household? Yes No If yes, are the other cats indoor, outdoor or both? Yes No Dogs only! Do you take your dog to obedience class? Yes No Do you take your dog to parks? Yes No Do you take your dog shopping at pet stores? Yes No Does your dog leave or escape out of your yard? Yes No If you answered yes to 2 or more questions, your pet is at risk for exposure to diseases from other pets. Environmental exposure: Cats & Dogs: Does your cat/dog get ticks? Yes No Does your cat/dog drink water in ditches, pastures, etc…? Yes No Do you live in a rural area? Yes No Does your cat/dog go into areas where deer and wildlife live? Yes No Do you have young children in the household? Yes No Do you travel to other places with your pet? Yes No Cats only! Does your cat hunt? Yes No Dogs only! Do you go hiking, camping or hunting with your dog? Yes No If you answered yes to 2 or more questions, your pet is at risk for exposure to disease from the environment. Remember: Both dogs and cats can get heartworms whether they are mostly indoor or outdoor. Preventatives are available for both! RABIES vaccination is required for ALL dogs and cats in Florida! CommentsThis field is for validation purposes and should be left unchanged.