Canine Annual Exam History

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Canine Annual Exam History

* Indicates required field

Pet's Name *

Client Name *

First

Last

Phone Number *

Email *

For today's visit the following symptoms are present: *

Coughing Sneezing Vomiting Diarrhea Lethargy Lameness Itching Lumps/Bumps No symptoms present Other Symptoms/concerns

Other Symptoms *

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? *

Yes No

Monthly heartworm/deworming/flea and tick preventive: *

None Bravecto Heartgard Plus Trifexis Comfortis Nexgard Revolution Frontline Advantage

Current medications/supplements and dose given: *

Diet: *

Appetite *

Normal Decreased Increased

Water Intake *

Normal Decreased Increased

Activity Level *

Normal Abnormal

Food Allergies: *

Other Allergies: *

Any seizures? *

Percentage of time spent indoors: *

History

How is your pet doing at home? *

Have you noticed any changes to their behavior? *

Yes No

What concerns would you like to address today? *

Do you need any medication refills? *

Yes No

Comment *

Vaccine Lifestyle Information and Consent

Do you take your pet hunting/hiking/camping/swimming, or playing in/near rivers? *

Yes No

Does your pet have exposure to standing water, puddles, parks, water features, etc? *

Yes No

Is there a possibility of sniffing the ground where rats or wildlife have been? *

Yes No

Does your dog go to day-care/grooming/boarding/dog parks? *

Yes No

Vaccines Accepted/Declined for Upcoming Year

DHPP (distemper/parvo vaccine) *

Accept Decline

Leptospirosis (transmitted in urine of animals - contagious to people): *

Accept Decline

DHLPP (if receiving both the DHPP and Lepto): *

Accept Decline

Rabies: *

Accept Decline

Bordetella (for kennel cough) *

Accept Decline

Entering Your Full Name Here Will Serve As Your Digital Signature *

Date *

Submit

Mountain View Veterinary Hospital 2014
300 S. Redwood Street, Suite 115
Canby, Oregon 97013

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