Pet Health Assessment - Dogs
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Be prepared! Complete the questionnaire below and share with your veterinarian at your next visit.

Pet Health Assessment - Dogs
Dog's Name
Gender  Age: Years Months  Weight lb
1. Has your dog’s weight changed unexpectedly recently?
My dog has lost interest in food and is losing weight
My dog is being fed the same amount but is losing weight
My dog is eating the same amount but is gaining weight
My dog is eating more and gaining weight
My dog’s weight has not changed recently
2. Have you noticed any recent changes in your dog’s water consumption?
My dog seems to be thirstier and drinks more water
My dog appears to drink less water than before
My dog drinks about the same amount of water as always
3. Have you noticed any of the following characteristics in your dog’s stool?
Nothing unusual
Fresh blood and/or mucus
Black, tarry color
Rice-like white specks on stool that sometimes move
4. Have you noticed any changes in your dog’s urination habits?
Nothing unusual
My dog urinates more frequently than before
My dog seems to strain to urinate
My dog urinates in inappropriate places
5. How would you describe the inside of your dog’s ears?
Normal (no discharge, skin smooth, mild pleasant odor)
Waxy (brown discharge from the ear)
Skin rough and dry in the ear
Skin moist and red with an unpleasant odor in the ear
6. Does your dog seem to be scratching excessively in any of the following areas?
Around the ears
All over the body
Around the anal area
My dog scratches only occasionally
7. How would you describe your dog’s skin?
Smooth, flesh-colored
Areas of red marks, bumps, or scales
8. Does your dog have any of the following breathing problems? (check all that apply)
A honking "cough"
Struggles to catch breath, especially after exercise
Wheezing
Bark has changed
Dog snores loudly
Panting
None of the above
9. How often do you take your dog to the veterinary clinic (not including emergencies)?
Twice a year
Annually
Every few years
Rarely or never
10. Is your dog on heartworm prevention?
Yes
No
11. When was the last time you took a stool sample to your veterinary clinic for examination?
Within the past year
More than a year ago
12. Has your dog received a dewormer in the last year?
Yes
No
13. Is your dog on a flea control treatment?
Yes
No
14. Is your dog on a tick control treatment?
Yes
No
15. How much time does your pet spend outside?
Rarely
For walks
25%
50%
75%
100%