Your NameDate Date Format: MM slash DD slash YYYY Dogs Name:Dogs Age:PART 1: Risk Assessment (To be completed by pet owner)Do you have multiple pets?YesNoDoes your dog go outdoors unsupervised?YesNoDoes your dog have an opportunity to drink from water outdoors (ponds, puddles, water bowls, etc.)?YesNoDo you ever take your dog to a boarding facility or groomer?YesNoHow often?Do you ever travel with your dog?YesNoIf so, whereDo you ever take your dog to dog shows?YesNoDo you hunt with your dog?YesNoHow many ticks does your dog get per year?Do you use tick control?YesNoIs your dog ever exposed to areas where there are rattlesnakes?YesNoHas your pet ever become sick or had a reaction after vaccination?YesNoIf so, which vaccine and what type of reaction?Is your dog on heartworm prevention medication?YesNoIf so, what brand?Has your dog missed a monthly heartworm prevention dose?YesNoIf so, when?Does your dog have any known diseases?YesNoIf so, what type?Is your pet on any other medications?YesNoIf so, please list type and dosagePART 2: Your dog’s recommended immunizations (to be completed by veterinarian) Distemper/Adenovirus/Parvovirus/Parainfluenza Rabies ***Required by law for all pets*** Leptospirosis (Yearly) Rattlesnake Vaccine Kennel Cough (Every 6 months) Lyme (Yearly) 1 Year3 YearDate Date Format: MM slash DD slash YYYY 1 Year3 YearDate Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY Rattlesnake vaccine may be recommended twice yearly for certain dogsDate Date Format: MM slash DD slash YYYY Date Date Format: MM slash DD slash YYYY
