Health Risk Questionnaire

Name
First Last
Phone
Email
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
- Other
How 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
- Other
How long have you had him/her?
Is your pet spayed/neutered?
- Yes
- No
At what age?
Where does your pet live mostly?
- Indoors
- Outdoors
Approximately how many hours a day?
Where does your pet sleep at night?
- Your bed
- Dog bed
- outside
- other
Please Specify
Check 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
- Neighborhood
Do you observe wild animals or other wildlife in your neighborhood?
- Yes
- No
Please Specify
- Feral
- Cats
- Squirrels
- Small Rodents
- Raccoons
- Opossum
- Rabbits
- Deer
- Geese
- Ducks
- Pigeons
- Seagulls
- Wild Canids
- Coyotes/Foxes
- Bats
- Other
Which 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 pets
Which states/countries has your pet lived in other than New York?
Does your pet travel with you outside of Long Island?
- Yes
- No
Where and how often?
Does your pet travel with you in? Check all that apply
- Car
- Plane
- Train
- Boat
Do 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
- No
Where?
- Walking
- Running
- Agility
- Swimming
What is the frequency?
Check what Brand/Type of food do you feed your pet?
- Dry
- Canned
- Home-Cooked
- Raw
- Freeze
- Dried
- Refrigerated
- Frozen
Is it nutrient complete & balanced?
How often do you feed and how much?
Does your pet have any food or other allergies/sensitivities?
- Yes
- No
Does 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
- No
Give details?
Do you use dental care products?
- Yes
- No
Which ones do you use?
Do you use Heartworm Preventative Products?
- Yes
- No
Which one do you use?
Do you use flea/tick control products?
- Yes
- No
Which do you use?
Has your pet ever had an adverse reaction to any Heartworm, Flea or Tick products?
- Yes
- No
Which 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
- No
Which vaccine(s) and describe what happened?
Do you have pet health insurance?
- Yes
- No
Which one?
Do you have concerns about your pets weight?
- Yes
- No
Do you have any questions or concerns about your pets overall health?
- Yes
- No
Please specify
Are there any immunocompromised children or adults living in the home?
- Yes
- No
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