Does your pet have mouth odor?

YES_____

NO_____

Does your pet have ear odor or does he scratch his ears a lot?

YES_____

NO_____

Does your pet have a discharge from his eyes?

YES_____

NO_____

Do you use a flea and tick control product?

YES_____

NO_____

Do you see fleas and/or ticks on your pet?

YES_____

NO_____

Does your pet scratch a lot?

YES_____

NO_____

Have you noticed reddened areas of skin?

YES_____

NO_____

Does your pet have a hair loss other than normal shedding?

YES_____

NO_____

Is your pet’s hair coat brittle and/or dull?

YES_____

NO_____

Does your pet have difficulty getting up or climbing stairs?

YES_____

NO_____

Does your pet seem more tired or have less energy?

YES_____

NO_____

Is your pet on heartworm preventive (Heartgard, Iverhart,  Interceptor,etc.)

YES_____

NO_____

Does your pet cough a lot?

YES_____

NO_____

Does your pet ever seem to have difficulty breathing?

YES_____

NO_____

Has your pet ever had a seizure?

YES_____

NO_____

Have you noticed any lumps or growths on your pet?

YES_____

NO_____

What do you feed your pet?____________________ Any table scraps?

YES_____

NO_____

Has your pet’s appetite decreased?

YES_____

NO_____

Has your pet’s water intake increased?

YES_____

NO_____

Have you noticed a weight gain or loss?

YES_____

NO_____

Have you noticed your pet vomiting?

YES_____

NO_____

If yes, for how long and how often? _____________________________

YES_____

NO_____

Does your pet urinate frequently or in odd places?

YES_____

NO_____

Have you seen blood in your pet’s urine?

YES_____

NO_____

Does your pet have soft stools or diarrhea?

YES_____

NO_____

Have you seen a bloody rectal discharge?

YES_____

NO_____

Have you seen a bloody genital discharge?

YES_____

NO_____

Has your pet strained to urinate or defecate?

YES_____

NO_____

Do you have any health concerns not mentioned above? ___________________________________

YES_____

NO_____