Pet Information Form - Veterinary Healthcare Associates
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1Pet’s Full Name: ____________________________________________
Age: ___________
Breed: ___________________________
Home Phone: _________________________________
Address: ___________________________________________________________
Email Address: _____________________________________________________________________________________________________
Female Intact
Female Spayed
Male Intact
Male Neutered
Does your pet have health insurance?
Yes
No
Is your pet the best dog in the whole world?
Yes
No
Is your dog microchipped?
Yes
No
Diet
My dog eats (Mark all that apply)
My dog:(Mark all that apply)
Dry dog food – Brand ____________________________
Is a picky eater
Canned or semi-moist food – Brand _________________
Will eat most types of dog food
Treats – Brand __________________________________
Is always begging for food
People food – Type ______________________________
Will eat anything that doesn’t eat him/her first
Lifestyle
My dog travels: (Mark all that apply)
Leptospirosis is a potentially fatal disease for dogs and people.
Around town
To the groomer
It is usually transmitted by contact with the urine of infected
Around Florida
To the pet resort or kennel
dogs, raccoons, rats, skunks, cows, pigs or sheep. This urine
To the Northeast or
To dog shows or classes
may be mixed with water in puddles, ponds or streams.
Great Lakes regions
Outdoors, always supervised
Do you think your dog has any potential to be exposed?
Internationally
Outdoors, unsupervised at times
Yes
No
Parasites
Have you seen either of these parasites on your pet within the last year?
Fleas
Ticks
Neither
Is your pet currently having problems with?
Fleas
Ticks
Neither
Are there children, expectant mothers or immunocompromised people exposed to your pet?
Yes
No
Is your pet on monthly heartworm preventative?
Yes Brand ______________________ Last date given __________________
No
Is your pet on monthly flea control
Yes Brand ______________________ Last date given __________________
No
?
Please circle any conditions that apply to your pet:
Vomiting
Diarrhea
Constipation
Incontinence
Normal (no problems)
Difficulty jumping
Limping
Difficulty with stairs
Seizures
Vision problems
Hearing problems
Behavioral changes
Increased thirst
Frequent urination
Coughing
Skin growths
Itchy skin
Bad breath
Is your pet a member of the “over 45” club?
Your pet’s health status depends on its body weight. This table will help you determine if your pet is senior or super senior by showing the
animal’s relative age in human years. Please circle your pet’s “human age”.
Animal’s age
Animals weight in pounds
Your pet’s weight __________lbs.
in years
0-20
21-50
51-90
over 90
1………….…….. 20…………. 18…………… 17…………… 15
2…………….….. 24…………. 23…………… 23…………… 20
3….…………….. 28…………. 28…………… 29…………… 27
4………………... 32…………. 33…………… 35…………… 35
5…………….….. 36…………. 38…………… 40…………… 42
6…..…….……… 40…………. 42……………
45………..….. 49
7………….…….. 44………….
47…………… 50………….... 56
Age Scale:
Adult
8………….……..
48…………. 51…………… 55……….…... 64
Senior
9….……………..
52…………. 56……………
61………..…..
Super Senior
71
10………….…….
56………….
60……………
66……….…... 78
11………….…….
60………….
65……………
72………..….. 86
12………….……. 64………….
69…………… 77………..….. 93
__________________________________________
13………….……. 68………….
74…………… 82………….. 101
Client Signature
14………….…….
72…………. 78…………… 88………….. 108
15………….…….
76…………. 83…………… 93………….. 115
16………….…….
80…………. 87…………… 99………….. 123
Date: ________/________/________
17………….…….
84…………. 92…………..
104…………… ---
18………….…….
88…………. 96…………..
109………..….. ---
Thank you for helping us keep your pet healthy!
19………….…….
92………… 101………….
115…………… ---
20………….…….
96………… 105………….
120…………… ---
V9.0529
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