Orchard Park Veterinary Medical Center

Form - Wellness Assessment Form

Name
First Name	Last Name

Pet's Name

Date

E-Mail Address :

What brings you in today?

For Dog & Cat Owners

Do you ever take your pet to a groomer, doggie daycare, shows, boarding, or training facilities?
Yes
No

Do you live in or exercise with your pet in a wooded area?
Yes
No

Do you travel with your pet to areas south of New York state?
Yes
No

Is your pet ever unsupervised while outside?
Yes
No

Does your pet live in a multi-pet household?
Yes
No

For Dogs Only

If your dog is on a monthly heartworm preventative, have you missed a dose by two months in a row?
Yes
No

Are there ticks in your area?
Yes
No

Does your dog have an opportunity to drink from ponds or other standing water?
Yes
No

For Cats Only

Does your cat go outdoors?
Yes
No

My Pet's Diet is:
Dry food only
Wet food only
Dry/wet mixed
Some people food
I cook for my pet

Please indicate any other food fed to your cat including brand, & how much:

For your visit today:

Please identify any concerns you have about your pet:
Weight
Appettite
Water consumption
Skin
Limping/lameness
Eyes
Ears
Teeth/Breath
Stool
Urination
Behavior

Other Services:

Do you need any prescriptions filled or refilled on the day of your visit? Please indicate below:

Interest in any additional services?

Do you have any interest in additional services such as acupunture, behavioral consults, etc...?
Yes
No

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