Your Name Date MM slash DD slash YYYY Dogs Name: Dogs Age: PART 1: Risk Assessment (To be completed by pet owner)Do you have multiple pets? Yes No Does your dog go outdoors unsupervised? Yes No Does your dog have an opportunity to drink from water outdoors (ponds, puddles, water bowls, etc.)? Yes No Do you ever take your dog to a boarding facility or groomer? Yes No How often? Do you ever travel with your dog? Yes No If so, where Do you ever take your dog to dog shows? Yes No Do you hunt with your dog? Yes No How many ticks does your dog get per year? Do you use tick control? Yes No Is your dog ever exposed to areas where there are rattlesnakes? Yes No Has your pet ever become sick or had a reaction after vaccination? Yes No If so, which vaccine and what type of reaction? Is your dog on heartworm prevention medication? Yes No If so, what brand? Has your dog missed a monthly heartworm prevention dose? Yes No If so, when? Does your dog have any known diseases? Yes No If so, what type? Is your pet on any other medications? Yes No If so, please list type and dosage PART 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 Year 3 Year Date MM slash DD slash YYYY 1 Year 3 Year Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Rattlesnake vaccine may be recommended twice yearly for certain dogsDate MM slash DD slash YYYY Date MM slash DD slash YYYY
