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%