Please answer the following questions. This information will allow the veterinary staff to best assess your pets' particular risk for certain preventable disease and help the staff target client education to better inform you about these diseases and zoonotic conditions.
What is your dog's/cat's name:
Is your dog/cat a Male or Female:
Does your pet ever go outdoors:
Is your pet ever outdoors unsupervised:
Does your pet come into contact with other pets or their environment:
If so, what kind: _________________________________________
Is there wildlife in your area, including mice, squirrels, birds, opossums, raccoons, or skunks: _______________________________________________
Are there ticks in your areas that you take your pet to (i.e. Trees, forests, brush):
Is your pet exposed to mosquitoes: ____________________________________
Does your pet have an opportunity to drink from standing water outdoors (ponds, puddles, etc.):
Does your pet sleep with you/your children: _____________________________
Do you ever take your pet to dog/cat shows: ____________________________
If so, how often: _____________
If your pet is a dog: Do you take your dog hunting: If so, how often/what time of year: ____________________________________
Is your pet spayed (females) or neutered (males): _______________________
Is your dog on heartworm preventative (If yes, year round?) _______________
If your dog is on heartworm preventative, have you ever missed a dose (injectable=every 6 months/pills=monthly) by more than two weeks:
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