Canine Health Questionnaire | City Way Clinic Mass Ave, IN

Client Name(Required)

First

Last

Pet Name(Required)

Health Questionnaire

Any changes in your dog’s drinking or urination?(Required)

Yes

If your dog's drinking or urination have changed, what changes have you noticed?

Has your dog’s weight or appetite changed in the last year?(Required)

Yes

If your dog's weight or appetite has changed, what changes have you noticed?

Have you noticed any new lumps or bumps on your dog?(Required)

Yes

If you have noticed any new lumps or bumps, where? Have they grown quickly?

Does your dog vomit or have diarrhea more than one time per week?(Required)

Yes

Does your dog’s breath stink?(Required)

Yes

Do you have any questions about at-home dental care?(Required)

Yes

Does your dog have any of the following arthritis signs? (Check all that apply):

difficulty going up/down stairs

slipping on non-carpeted areas

not playing/running as much

obvious limping/lameness

slow to get up after laying down

difficulty getting into vehicles

not going for as long of walks anymore

getting tired easier

If you have noticed any of these arthritic signs, are you interested in learning more about services or products that could help?(Required)

Yes

Do you have any concerns about fleas or ticks?(Required)

Yes

Does your dog have any history of allergies?(Required)

Examples: vaccines, food, medications, seasonal, etc.

Yes

If your dog has a history of allergies, please explain.

Do you have concerns about your dog’s behavior?(Required)

Yes

If you do have concerns about your dog's behavior, please explain:

Do you have any major changes upcoming that could affect your dog?(Required)

Yes

If your have major changes upcoming, please explain:

Are you interested in a microchip for your dog today?(Required)

Yes

Do you have any other concerns about your dog today?

Vaccine Risk Assessment

CORE VACCINES – These vaccines are considered vital to all canines based on a universal risk of exposure, the severity of disease, and the risk of transmission to other animals including human beings.

RABIES is a fatal, viral disease most often transmitted through the bite of an infected animal. Most mammals are susceptible to this disease including humans. Vaccination is required by law in the state of Indiana.

DISTEMPER/HEPATITIS/PARAINFLUENZA/PARVO** are viral diseases that are commonly spread from dog to dog but can exist in wildlife as well. Distemper is a fatal viral illness with no direct treatment available. Hepatitis (Adenovirus 2) and Parainfluenza are both highly contagious upper respiratory illnesses. Parvovirus can be fatal and is very contagious to unvaccinated or under vaccinated dogs – mostly affecting puppies and senior pets.

LEPTOSPIROSIS** is a bacterial disease that can be found in most animals, including wildlife (deer, raccoons, opossums, skunks, and rodents) and other dogs. The bacteria are passed via the urine and are present in any stagnant surface water, most soil, and recreational sources, such as ponds and lakes. Leptospirosis is a contagious disease and can be transmitted from dog to dog and dog to human. If infected, these bacteria can be fatal.

It causes kidney and liver failure. Treatment includes several days of quarantined hospitalization, antibiotics, and supportive care.

NON-CORE VACCINES – Please determine your pet’s level of risk to these diseases, taking into account their lifestyle, current health status, and amount of close contact with other animals and humans. We will be happy to review this with you and discuss further at your appointment.

LYME DISEASE** is caused by bacteria that are transmitted through certain tick species, including the deer tick and western black legged tick. Your dog is at an increased risk of contracting Lyme disease if it spends time in wooded areas or low-growing grasslands, or spends time outdoors during peak tick season. Visits to Lyme endemic areas of the Northeast, Mid-Atlantic, or upper Midwest also put your dog at risk. If you have ever found a tick on your dog, vaccination is recommended. If infected, Lyme disease can cause joint swelling, lameness, fever, and kidney failure. It is thought that once your dog is infected, it is extremely difficult, if not impossible, to clear the bacteria from the body.

Lyme Disease Vaccination(Required)

I want to vaccinate my dog from Lyme disease due to its risk.

I DO NOT want to vaccinate my dog from Lyme disease.

CANINE COUGH (Bordetella) is an upper respiratory disease similar to the common cold. The cough can be quite persistent and is usually of a dry hacking nature. This discomfort can last up to 12 weeks. Very young, older, or otherwise immunocompromised dogs are at a higher risk of developing a more severe form of canine cough. Your dog can catch this disease simply by coming into contact with dogs that have it, in such places as boarding kennels, grooming salons, local parks, or neighborhoods. Most kennels require vaccination against canine cough before admittance. The duration of vaccine is 12-14 months, but the recommendation with risk of increased contact is vaccinating every 6 months.

Canine Cough (Bordetella)(Required)

I want to vaccinate my dog from Bordetella due to its risk or pet facility requirement.

I DO NOT want to vaccinate my dog from Canine Cough.

CANINE INFLUENZA** is an upper respiratory disease similar to the flu. The symptoms of canine influenza are similar to the human flu: cough, runny nose, and fever. It is easily transmitted through respiratory secretions (sneezing, coughing, nasal discharge). Dogs with influenza may develop pneumonia that might require hospitalization. Vaccination against canine flu should be considered for any at-risk breed, dogs with heart or respiratory conditions, dogs that travel or show, and those that have extensive contact with other dogs (boarding, grooming, training facilities, and dog parks).

Canine Influenza(Required)

I want to vaccinate my dog for Influenza due to its risk or pet facility requirement.

I DO NOT want to vaccinate my dog from Canine Influenza.

Has your dog had an adverse reaction to vaccines in the past?(Required)

Yes

Date of adverse reaction(Required)

Explain the adverse reaction from vaccines in the past.(Required)

Authorization

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Today's Date(Required)

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Canine Health Questionnaire + Vaccine Risk Assessment

Health Questionnaire

Vaccine Risk Assessment

Authorization

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317-396-0056

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317-396-0056