Doggie Daycare Registration – Los Gatos Dog & Cat Hospital

Today's Date

Owner's Name

First Last

Pet's Name

Species

Gender

Age/DOB

Describe your pet's daily activity level

Has your pet's activity level changed since your last visit?

Yes
No

Have you noticed any stiffness or change in your pet's mobility?

Yes
No

Example: not jumping, slow to stand, etc.

How would you describe your pet's weight?

What is your pet's diet?

Example:
Brand: Nutro - Form: kibble - Amount: 1/4 cup - Frequency: 2 x day - Fed since: Jan 2010

How would you describe your pet's appetite and water consumption?

Please list your pet's current medications.

Example:
Medication: Hydroxyzine - Strength: 10mg - Frequency: every 12 hours

Is your pet taking any supplements? (including naturopathic formulas, nutraceuticals, etc.)

Yes
No

Has your pet ever had a reaction to a vaccine, medication or food?

Yes
No

Is your pet on a flea and tick prevention?

Yes
No

Heartworm prevention?

Yes
No

What brand?

When was the last dose given?

Are there any chronic signs that your pet has that you would like to be addressed at this visit? Of these issues, which is the most concerning at this time?

Does your pet live

What kind of area do you live in?

Does your pet go to a grooming facility on a regular basis?

Yes
No

Does your dog go to the dog park, daycare or boarding facility?

Yes
No

Are there raccoons, opossums, squirrels, deer, rodents or other wildlife species in your area?

Yes
No

Has your pet ever had...

Fleas
Ticks
Both

Is your dog a hunting dog?

Yes
No

Has your pet traveled within the last 3 years, where?

Will you be traveling with your pet in the future?

Yes
No

Do you have a second home that your pet visits regularly, where?

Are there small children, seniors or other immune compromised persons living with your pet?

Yes
No

If yes, are your interested in discussing potential animal to human disease transmission risks?

Yes
No

Are you interested in alternative medicine, such as acupuncture or laser therapy, for your pet?

Yes
No

Wellness Questionnaire 2

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