Health Risk Questionnaire Name First Last PhoneEmail Please review and answer the following questions to help us individualize your pet’s healthcare recommendations:What kind are in your household? Dog Cat Bird OtherHow many pets.How old was your pet when you got him/her?If pure breed or mixed-breed, what type is your pet?Where did you get your pet from? Breeder Pet Store Shelter OtherHow long have you had him/her?Is your pet spayed/neutered? Yes NoAt what age?Where does your pet live mostly? Indoors OutdoorsApproximately how many hours a day?Where does your pet sleep at night? Your bed Dog bed outside otherPlease SpecifyCheck all the places that your pet does go. Indoor only Backyard Porch Patio Deck Obedience Training or Agility Classes Pet Stores Dog Parks Hiking Hunting Camping Fishing Forest Preserves Communal areas adjacent to a subdivision Apartment Condo Groomer Show Ring Bathing Facility NeighborhoodDo you observe wild animals or other wildlife in your neighborhood? Yes NoPlease Specify Feral Cats Squirrels Small Rodents Raccoons Opossum Rabbits Deer Geese Ducks Pigeons Seagulls Wild Canids Coyotes/Foxes Bats OtherWhich of the following is true? Other pets visit our home/yard My pet visits other homes with pets We foster dogs We feed our pets outside We feed wild animals/feral cats We have previously seen parasites on our petsWhich states/countries has your pet lived in other than New York?Does your pet travel with you outside of Long Island? Yes NoWhere and how often?Does your pet travel with you in? Check all that apply Car Plane Train BoatDo you employ anyone to look after your pet? (Dog Walker/Daycare/Boarding)If your pet does go to a boarding kennel or groomer, where and how often?Does your pet get regular exercise? Yes NoWhere? Walking Running Agility SwimmingWhat is the frequency?Check what Brand/Type of food do you feed your pet? Dry Canned Home-Cooked Raw Freeze Dried Refrigerated FrozenIs it nutrient complete & balanced?How often do you feed and how much?Does your pet have any food or other allergies/sensitivities? Yes NoDoes your pet get treats? What kind and how many per day?Please list any and all vitamins/supplements your pet gets?Has your pet ever been diagnosed or treated for any disease condition?Please list any and all medications your pet receives on a regular basis?Has your pet ever had an adverse reaction to any medications or supplements? Yes NoGive details?Do you use dental care products? Yes NoWhich ones do you use?Do you use Heartworm Preventative Products? Yes NoWhich one do you use?Do you use flea/tick control products? Yes NoWhich do you use?Has your pet ever had an adverse reaction to any Heartworm, Flea or Tick products? Yes NoWhich one(s) and describe reaction?Do you know if any, what vaccines your pet has received?Has your pet over had an adverse reaction to vaccines? Yes NoWhich vaccine(s) and describe what happened?Do you have pet health insurance? Yes NoWhich one?Do you have concerns about your pets weight? Yes NoDo you have any questions or concerns about your pets overall health? Yes NoPlease specifyAre there any immunocompromised children or adults living in the home? Yes No
